286 |
2020-10-21 18:32 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
287 |
2020-10-21 18:35 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Gary George Bilyeu |
garygb1990@gmail.com |
Sparta |
Christian |
Missouri |
Daniel Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary George Bilyeu |
garygb1990@gmail.com |
Owner |
Sparta |
Christian |
Missouri |
Chad Anthony Charles |
Daniel Bilyeu |
Signed |
288 |
2020-10-21 18:36 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
545 |
2021-06-22 12:58 |
Anonymous (not verified) |
97.88.95.170 |
Peter L. Viscusi |
Proprietorship |
328 Jones Avenue, Warrensburg, MO 64093 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-22 |
Peter L. Viscusi |
pviscusi@charter.net |
Warrensburg |
Johnson |
Missouri |
Bradley S. McGuffey |
Randel C. Kyle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peter L. Viscusi |
pviscusi@charter.net |
Self |
Warrensburg |
Johnson |
Missouri |
Bradley S. McGuffey |
Randel C. Kyle |
Signed |
1593 |
2023-04-24 09:41 |
Anonymous (not verified) |
94.188.207.225 |
Tyler Wilson |
Proprietorship |
5319 Ruhd Street Southwest, Cedar Rapids, IA 52404, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-24 |
Tyler Wilson |
t.wilson237@gmail.com |
Cedar Rapids |
Linn |
Missouri |
Jordan Loyd |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Robert Snyder |
Signed |
2047 |
2024-02-15 16:58 |
Anonymous (not verified) |
94.188.205.177 |
PorchLight Insights LLC |
Limited Liability Company |
2918 Campbell Street, Kansas City, MO 64109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Kate Regnier Bender |
kate.bender@porchlightinsights.com |
Kansas City |
Jackson |
Missouri |
Jonathan Bender |
Brandon Steenson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kate Regnier Bender |
kate.bender@porchlightinsights.com |
Co-Founder |
Kansas City |
Jackson |
Missouri |
Jonathan Bender |
Brandon Steenson |
Signed |
131 |
2020-04-27 15:01 |
Anonymous (not verified) |
66.188.136.150 |
Hashem Shawki |
Proprietorship |
8906 Newton Ave. S |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Hashem Shawki |
kschumacher@tricorinsurance.com |
Bloomington |
Hennepin |
MN |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hasham Shawki |
kschumacher@tricorinsurance.com |
Same person |
Bloomington |
Hennepin |
MN |
Russell Masartis |
Nancy Wortley |
Signed |
198 |
2020-07-08 17:35 |
Anonymous (not verified) |
162.218.47.214 |
Olsem Aerial Application Services LLC |
Limited Liability Company |
34538 County Road 13 Westbrook MN 56183 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-08 |
Benjamin Olsem |
oaasllc@gmail.com |
Westbrook |
Cottonwood |
MN |
Megan Olsem |
Tobin Richards |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benjamin Olsem |
oaasllc@gmail.com |
Owner/Self |
Westbrook |
Cottonwood |
MN |
Megan Olsem |
Tobin Richards |
Signed |
373 |
2021-01-25 09:06 |
Anonymous (not verified) |
66.188.136.150 |
Daniel Kulberg |
Proprietorship |
PO Box 641, Renville, MN 56284 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-25 |
Daniel Kulberg |
kschumacher@tricorinsurance.com |
Renville |
Renville |
MN |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Kulberg |
kschumacher@tricorinsurance.com |
Same |
Reville |
Renville |
MN |
Russell Masartis |
Shuree Behr |
Signed |
500 |
2021-04-29 13:09 |
Anonymous (not verified) |
204.155.61.217 |
JWJ Home Remodeling LLC |
Limited Liability Company |
16915 Weaver Lake Dr, Maple Grove MN 55311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-29 |
Jackson Janzen |
jacksonjanzen@hailmayday.com |
Maple Grove |
hennepin |
MN |
Ashley Kraft |
DocuSign |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jackson Janzen |
jacksonjanzen@hailmayday.com |
Owner |
Maple Grove |
Hennepin |
MN |
Ashley Kraft |
DocuSign |
Signed |
818 |
2022-01-02 11:34 |
Anonymous (not verified) |
184.94.130.66 |
dylan nelson trucking llc |
Limited Liability Company |
2011 465th street hanley falls mn 56245 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
dylan nelson |
dylancvi@gmail.com |
hanley falls mn |
yellow medicine |
mn |
derek verhelst |
mike fales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
dylan nelson |
dylancvi@gmail.com |
owner |
hanley falls mn |
yellow medicine |
mn |
derek verhelst |
mike fales |
Signed |
819 |
2022-01-02 11:39 |
Anonymous (not verified) |
184.94.130.66 |
derek verhelst trucking inc |
Proprietorship |
1579 270th avenue canby mn 56220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
derek verhelst |
derekvtinc@gmail.com |
canby |
yellow medicine |
mn |
lois verhelst |
dylan nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
derek verhelst |
derekvtinc@gmail.com |
owner |
canby |
yellow medicine |
mn |
lois verhelst |
dylan nelson |
Signed |
928 |
2022-02-17 19:46 |
Anonymous (not verified) |
208.83.187.211 |
Eric Marsh Trucking LLC |
Limited Liability Company |
1029 Davis Ave Westbrook MN 56183 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Eric Marsh |
emt78@yahoo.com |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Marsh |
emt78@yahoo.com |
Self |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
1136 |
2022-05-31 13:46 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI BURRITO COMPANY LLC |
Limited Liability Company |
39502 710TH ST LAKEFIELD, MN 56105 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
SELF |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
507 |
2021-05-10 10:20 |
Anonymous (not verified) |
192.30.186.37 |
Stowe's Drywall |
Proprietorship |
PO Box 712, Ponca, NE 68776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Danny Stowe |
deb.nana.stowe@gmail.com |
Ponca |
Dixon |
NE |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Danny Stowe |
deb.nana.stowe@gmail.com |
Owner |
Ponca |
Dixon |
NE |
Katie Jenks |
Virginia Anderson |
Signed |
1096 |
2022-05-12 15:47 |
Anonymous (not verified) |
64.64.128.230 |
Tim Woslager |
Limited Liability Company |
612 West 8th St Neligh Ne 68756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-12 |
Tim Woslager |
timwoslager@icloud.com |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Woslager |
timwoslager@icloud.com |
Owner |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
1097 |
2022-05-12 15:47 |
Anonymous (not verified) |
64.64.128.230 |
Tim Woslager |
Limited Liability Company |
612 West 8th St Neligh Ne 68756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-12 |
Tim Woslager |
timwoslager@icloud.com |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Woslager |
timwoslager@icloud.com |
Owner |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
1855 |
2023-09-27 12:56 |
Anonymous (not verified) |
94.188.207.224 |
Lincoln Hotel Group |
Limited Liability Company |
9240 Andermatt Drive Suite 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. |
2023-09-27 |
John Edward Klimpel |
jklimpel@lincolnhotelgroup.com |
Lincoln |
Lancaster |
NE |
Carrie A. Fleck |
Jill N. Korta |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brent Besch |
brent.besch@marshmma.com |
Client |
Lincoln |
Nebraska |
NE |
Carrie A Fleck |
Jill N Korta |
Signed |
2089 |
2024-03-12 10:58 |
Anonymous (not verified) |
94.188.205.166 |
Margarito R Guzman |
Proprietorship |
4512 S 22nd ST Omaha NE 68107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-12 |
Margarito R Guzman |
abrahamguzman030@gmail.com |
omaha |
douglas |
NE |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Margarito Guzman |
abrahamguzman030@gmail.com |
Owner |
Omaha |
Douglas |
Nebraksa |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
39 |
2020-01-19 11:00 |
Anonymous (not verified) |
75.163.84.145 |
Allen L Bryen |
Proprietorship |
2609 Madison St Bellevue NE 68005 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-19 |
Allen Lee Bryen |
Allen.Bryen@yahoo.com |
Bellevue |
Sarpy |
Nebraska |
Jeffrey Coats |
Donald Coats |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Allen L Bryen |
Allen.Bryen@yahoo.com |
Self |
Bellevue |
Sarpy |
Nebraska |
jeffrey Coats |
Donald Coats |
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 |
940 |
2022-03-01 11:08 |
Anonymous (not verified) |
216.51.251.31 |
trent montgomery trucking llc |
Limited Liability Company |
1432 eagle ridge circle pierce ne 68767 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-01 |
trent montgomery |
trent.montgomery7@gmail.com |
pierce |
pierce |
nebraska |
warren montgomery |
travis montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
trent montgomery |
trent.montgomery7@gmail.com |
self |
pierce |
pierce |
nebraska |
warren douglas montgomery |
travis warren montgomery |
Signed |
1105 |
2022-05-16 13:40 |
Anonymous (not verified) |
174.235.192.160 |
Travis Montgomery Trucking LLC |
Limited Liability Company |
701 N 4th street Plainview Ne 68769 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Travis Montgomery |
travismontgomery76@gmail.com |
Plainview |
Pierce |
Nebraska |
Tim Woslager |
Trent Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Montgomery Trucking LLC |
travismotgomery76@gmail.com |
Owner |
Plainview |
Pierce |
Nebraska |
Trent Montgomery |
Tim woslager |
Signed |
1106 |
2022-05-16 13:40 |
Anonymous (not verified) |
174.235.192.160 |
Travis Montgomery Trucking LLC |
Limited Liability Company |
701 N 4th street Plainview Ne 68769 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Travis Montgomery |
travismontgomery76@gmail.com |
Plainview |
Pierce |
Nebraska |
Tim Woslager |
Trent Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Montgomery Trucking LLC |
travismotgomery76@gmail.com |
Owner |
Plainview |
Pierce |
Nebraska |
Trent Montgomery |
Tim woslager |
Signed |
1149 |
2022-06-09 17:43 |
Anonymous (not verified) |
174.235.192.238 |
Bryan Linares |
Limited Liability Company |
630 Hawthorne 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. |
2022-06-09 |
Bryan Linares |
bryan.linares7798@gmail.com |
Crete |
Saline |
Nebraska |
Bryan Linares |
Chris Linares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Linares |
chris5linares1995@gmail.com |
Brother |
Crete |
Saline |
Nebraska |
Bryan Linares |
Chris Linares |
Signed |
1423 |
2023-01-16 14:03 |
Anonymous (not verified) |
173.224.19.200 |
Hoofin-It |
Proprietorship |
86148 537th Ave. Plainview, NE 68769 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-16 |
Chase Terrill |
terrill365@gmail.com |
Pierce |
Pierce |
Nebraska |
Jim Aschoff |
Calan List |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cole Aschoff |
aschoff_2@icloud.com |
Co-Owner |
Plainview |
Pierce |
Nebraska |
Jim Aschoff |
Calan List |
Signed |
1466 |
2023-02-17 15:12 |
Anonymous (not verified) |
94.188.207.230 |
BIG Roofing, LLC |
Limited Liability Company |
5751 NE 22nd St. #304 Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Tyler Jeffrey Baugh |
tj@bigroofing515.com |
Lincoln |
Lancaster |
Nebraska |
Steven Bieghler |
Andrew John Kohles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Craig Bieghler |
steve@bigroofing515.com |
Owner |
Cumming |
Dallas |
Iowa |
Tyler Jeffrey Baugh |
Andrew John Kohles |
Signed |
1726 |
2023-07-07 18:22 |
Anonymous (not verified) |
94.188.205.168 |
D&E LLC DBA Kanesville Valley |
Limited Liability Company |
P.O. Box 337 Council Bluffs, IA, 51502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Damien Joseph Shull |
damienshull@gmail.com |
Omaha |
Douglas |
Nebraska |
Angela Shull |
John Shull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Damien Joseph Shull |
damienshull@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Angela Shull |
John Shull |
Signed |
2029 |
2024-02-07 09:51 |
Anonymous (not verified) |
94.188.207.223 |
Jorge Llanos |
Proprietorship |
3304 Le Mesa Way, South Sioux City, NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-07 |
Jorge Llanos |
jorge.llanos123708@gmail.com |
South Sioux City |
Dakota |
Nebraska |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Acosta |
macosta@leafhome.com |
Recruiter |
Sioux Falls |
Minnehaha |
South Dakota |
Cody Dunbar |
Jordan Nisiewicz |
Signed |
2117 |
2024-03-27 10:38 |
Anonymous (not verified) |
94.188.207.226 |
ALCON CONSTRUCTION LLC |
Limited Liability Company |
2613 GINDY DR, BELLEVUE, NE 68147 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
VALERIE OLONO |
ALCONCONSTRUCTION2021@GMAIL.COM |
BELLEVUE |
SARPY |
NEBRASKA |
VICTOR H OLONO GANDARILLA |
ALEXANDRA GUTIERREZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
VALERIE OLONO |
ALCONCONSTRUCTION2021@GMAIL.COM |
SELF |
BELLEVUE |
SARPY |
NEBRASKA |
VICTOR H OLONO GANDARILLA |
ALEXANDRA GUTIERREZ |
Signed |
2119 |
2024-03-27 14:27 |
Anonymous (not verified) |
94.188.205.169 |
juan garcia |
Proprietorship |
3359 Patrick Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
Juan Garcia |
garcia.stone2022@gmail.com |
omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Garcia |
garcia.stone2022@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |
2123 |
2024-03-28 10:42 |
Anonymous (not verified) |
94.188.207.229 |
J&J Masonry |
Proprietorship |
2519 Poppleton Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-28 |
Jose Marroquin |
drakkarhr7@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Marroquin |
drakkarhr7@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2126 |
2024-03-29 09:35 |
Anonymous (not verified) |
94.188.207.227 |
MPO Masonry |
Proprietorship |
5027 s 20th at apt 12 Omaha ne 68107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-29 |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2128 |
2024-03-29 09:52 |
Anonymous (not verified) |
94.188.207.228 |
Mason Quality and Sons LLC |
Proprietorship |
18921 Willow St Omaha Ne 68136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-29 |
Joel Castillo |
drake.centurion@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Castillo |
drake.centurion@gmail.com |
self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
702 |
2021-11-01 09:23 |
Anonymous (not verified) |
173.28.195.56 |
Garcia Snow Removal |
Limited Liability Company |
213 E 7th Street, West Liberty, Iowa 52776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-01 |
Benji A Garcia |
garciabenji23@gmail.com |
West Liberty |
IA |
Norway |
Luis Ordenana-Choez |
Vicente Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benji Garcia |
garciabenji23@gmail.com |
Member |
West Liberty |
Muscatine |
Iowa |
Luis Ordenana-Choez |
Vicente Garcia |
Signed |
1864 |
2023-10-09 09:52 |
Anonymous (not verified) |
94.188.207.223 |
Admiral Staffing Inc |
Limited Liability Company |
580 8th Ave, 15th Floor, New York NY 10018 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Rezwan Rafeek |
ray@admiralstaffinginc.com |
23 Catalpa Lane |
Valley Stream |
NY |
Ikbal Sherif |
Salim Balee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shafi Rafeek |
shafi@admiralstaffinginc.com |
Office Manager |
New York |
NY |
United States |
Ikbal Sherif |
Salin Balee |
Signed |
166 |
2020-05-27 11:48 |
Anonymous (not verified) |
66.188.136.150 |
Kevin Kerstetter |
Proprietorship |
1080 E 12th St. Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-26 |
Kevin Kerstetter |
kschumacher@tricorinsurance.com |
Cuyahoga Falls |
Summit County |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Kerstetter |
kschumacher@tricorinsurance.com |
Same |
Cuyahoga Falls |
Summit County |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
167 |
2020-05-27 11:51 |
Anonymous (not verified) |
66.188.136.150 |
Dennis Heinlen |
Proprietorship |
3415 Upland Rd. Lowellville, OH |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-26 |
Dennis Heinlen |
kschumacher@tricorinsurance.com |
Lowellville |
Mahoning |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dennis Heinlen |
kschumacher@tricorinsurance.com |
Same |
Lowellville |
Mahoning |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
279 |
2020-10-19 08:02 |
Anonymous (not verified) |
66.188.136.150 |
Keith McNair |
Proprietorship |
13436 Silver Brook Dr. Pickerington, OH 43147 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-16 |
Keith McNair |
kschumacher@tricorinsurance.com |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith McNair |
kschumacher@tricorinsurance.com |
Same |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
356 |
2021-01-11 19:39 |
Anonymous (not verified) |
66.188.136.150 |
David Whitfield |
Proprietorship |
3947 Cracker Cove Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-11 |
David Whitfield |
kschumacher@tricorinsurance.com |
Canal Winchester |
Fairfield |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Whitfield |
kschumacher@tricorinsurance.com |
Same |
Canal Winchester |
Fairfield |
OH |
Russell Masartis |
Nancy Wortley |
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 |
828 |
2022-01-11 10:34 |
Anonymous (not verified) |
74.215.151.63 |
Marr Arnold Planning |
Limited Liability Company |
1328 California Ave. Ames Iowa 50014 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-11 |
Sarah Arnold |
sarahkarnold@gmail.com |
Cincinnati |
Hamilton |
Ohio |
April Humphreys |
Amy Burns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Arnold |
sarah@marrarnoldplanning.com |
Self |
Cincinnati |
Hamilton |
Ohio |
Amy Burns |
April Humphreys |
Signed |
369 |
2021-01-22 10:02 |
Anonymous (not verified) |
66.188.136.150 |
Rick Swaney |
Proprietorship |
1551 Persimmon, Stilwell, OK 74960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Rick Swaney |
kschumacher@tricorinsurance.com |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Swaney |
kschumacher@tricorinsurance.com |
Same |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
372 |
2021-01-25 08:38 |
Anonymous (not verified) |
66.188.136.150 |
Sawa Cheroke Transport, LLC |
Limited Liability Company |
PO Box 168, Stilwell, OK 74960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-25 |
Lisa Pritchett |
kschumacher@tricorinsurance.com |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sawa Cheroke Transport, LLC |
kschumacher@tricorinsurance.com |
Same |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
1032 |
2022-04-05 09:21 |
Anonymous (not verified) |
75.89.4.2 |
KG land works |
Limited Liability Company |
812 cr 2401 barnsdall Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Wyatt ray slone |
wyattslone177@gmail.com |
Barnsdalll |
Osage |
OK |
Dalton Gardner |
Colton Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Day helper |
Barnsdalll |
Osage |
OK |
Colton Kelley |
Dalton Gardner |
Signed |
1121 |
2022-05-19 17:45 |
Anonymous (not verified) |
107.115.239.35 |
KG Land works LLC |
Limited Liability Company |
P.O. Box 931Barnsdall Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-19 |
Keiven Brooke Slone |
keiven.slone@gmail.com |
Barnsdalll |
Osage |
OK |
Colton Kelley |
Dalton Gardner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Owner |
Barnsdalll |
Osage |
OK |
Dalton Garder |
Jacob Kelley |
Signed |
964 |
2022-03-10 12:41 |
Anonymous (not verified) |
107.115.239.27 |
KG Land Works LLC |
Limited Liability Company |
P.O. Box 931 Barnsdall Ok 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-10 |
Colton Kelley |
kglandworks@gmail.com |
Barnsdall |
Osage |
Oklahoma |
Colton Kelley |
Dalton Gardner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Owner |
Barnsdall |
Osage |
Oklahoma |
Colton Kelley |
Dalton Gardner |
Signed |
965 |
2022-03-10 12:44 |
Anonymous (not verified) |
107.115.239.27 |
KG Land Works LLC |
Limited Liability Company |
P.O. Box 931 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-10 |
Dalton Gregory Gardner |
kglandworks@gmail.com |
Barnsdall |
Osage |
Oklahoma |
Dalton Gardner |
Colton Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Gardner |
kglandworks@gmail.com |
Owner |
Barnsdall |
Osage |
Oklahoma |
Dalton Gardner |
Colton Kelley |
Signed |
1033 |
2022-04-05 09:36 |
Anonymous (not verified) |
75.89.4.2 |
KG Land Works |
Limited Liability Company |
PO Box 931 Barnsdall, Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Jacob Curtis Kelley |
jacobkelley730@gmail.com |
Barnsdall |
Osage |
Oklahoma |
Josiah Daniel Gott |
Ainsley Noelle Cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Gardner |
kglandworks@gmail.com |
Owner |
Barnsdall |
Osage |
Oklahoma |
Josiah Daniel Gott |
Wyatt Ray Slone |
Signed |
1196 |
2022-07-11 08:13 |
Anonymous (not verified) |
166.181.85.207 |
KG Land works |
Proprietorship |
P.O. Box 931 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-12 |
Noah Wassom |
nowhwassom@yahoo.com |
Barnsdall |
Osage |
OKLAHOMA |
Dalton Gardner |
Jacob Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colten Kelley |
KGlandworks@gmail.com |
Boss |
Barnsdall |
Osage |
OKLAHOMA |
Keiven Slone |
Whyatt Slone |
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 |
557 |
2021-07-07 09:51 |
Anonymous (not verified) |
66.188.136.150 |
Andrew Thompson-Sutherland |
Proprietorship |
3200 Daniel Lane Apt. 207 Monroeville, PA 15146 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-06 |
Andrew Thompson-Sutherland |
kschumacher@tricorinsurance.com |
Monroeville |
Allegheny |
PA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Thompson-Sutherland |
kschumacher@tricorinsurance.com |
Same |
Monroeville |
Allegheny |
PA |
Mitch Kemp |
Shuree Behr |
Signed |
150 |
2020-05-06 10:59 |
Anonymous (not verified) |
76.190.229.163 |
RNR Holdings LLC |
Limited Liability Company |
4330 Winter Eagle Trail SE Apt B, 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. |
2020-05-06 |
Richard E. White |
rwhite245@yahoo.com |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard E White |
rwhite245@yahoo.com |
Owner |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
109 |
2020-04-03 12:42 |
Anonymous (not verified) |
174.219.131.25 |
Upright Construction |
Limited Liability Company |
2514 S norton ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-03 |
Maurice Williams |
uprightway@mail.com |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maurice Williams |
uprightway@mail.com |
Owner |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
387 |
2021-02-08 14:26 |
Anonymous (not verified) |
192.30.185.142 |
Go 2 Girls |
Proprietorship |
104 Doral Lane, Dakota Dunes, SD 57049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-08 |
Tawnya Oneill |
tawny5881@gmail.com |
Dakota Dunes |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tawnya Oneill |
tawny5881@gmail.com |
Owner |
Dakota Dunes |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
435 |
2021-03-15 15:09 |
Anonymous (not verified) |
192.30.185.142 |
Marx Construction |
Proprietorship |
33044 484th Ave, Jefferson, SD 57038 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-15 |
Tony Marx |
tmarx416@hotmail.com |
Jefferson |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tony Marx |
tmarx416@hotmail.com |
Owner |
Jefferson |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
807 |
2021-12-20 09:30 |
Anonymous (not verified) |
63.153.145.38 |
Jerry Ollerich Trucking |
Proprietorship |
46884 267th Street Sioux Falls SD 57106 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-20 |
Jerald William Ollerich |
jeanollerich@yahoo.com |
Sioux Falls |
Minnehaha |
SD |
James K. Ollerich |
Joanne K. Berg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jean Staebell Ollerich |
jeanollerich@yahoo.com |
Wife/manager |
Sioux Falls |
Minnehaha |
SD |
James K. Ollerich |
Joanne K. Berg |
Signed |
1175 |
2022-07-05 07:56 |
Anonymous (not verified) |
64.251.168.116 |
Daniel Alan Valburg |
Proprietorship |
27656 SD Hwy 44 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Dan A Valburg |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvic |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Alan Valburg |
agflyer620@gwtc.net |
proprieter |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
1176 |
2022-07-05 08:08 |
Anonymous (not verified) |
64.251.168.116 |
Lucky Dude |
Proprietorship |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Lucky Dude |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucky Dude |
agflyer620@gwtc.net |
proprietor |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
1498 |
2023-03-07 11:20 |
Anonymous (not verified) |
94.188.205.176 |
KATEN LLC |
Limited Liability Company |
5100 S ASH GROVE AVE SIOUX FALLS, SD 57108 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
MIKE KLEIN |
joel@walkerinsuranceia.com |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MIKE KLEIN |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1500 |
2023-03-07 11:22 |
Anonymous (not verified) |
94.188.205.177 |
KATEN LLC |
Limited Liability Company |
5100 S ASH GROVE AVE SIOUX FALLS, SD, 57108 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-27 |
MICHELLE KATEN |
JOEL@WALKERINSURANCEIA.COM |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MICHELE KATEN |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORINGJ |
JENNIFER JANET YOUNGWIRTH |
Signed |
217 |
2020-07-27 14:56 |
Anonymous (not verified) |
72.2.163.232 |
Calvin Kroger |
Proprietorship |
48232 292nd St. Hudson, SD 57034 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-27 |
Calvin Kroger |
calvinkroger@gmail.com |
Hudson |
Lincoln |
South Dakota |
Robin Anderson |
Adam Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Calvin Kroger |
calvinkroger@gmail.com |
proprietor |
Hudson |
Lincoln |
South Dakota |
Robin Anderson |
Adam Anderson |
Signed |
933 |
2022-02-23 10:57 |
Anonymous (not verified) |
104.37.139.87 |
Jacobsen Transfer |
Limited Liability Company |
1773 20th rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-23 |
Austin Moffat |
austinmoffatt@gmail.com |
tabor |
von homme |
south dakota |
austin moffatt |
jesse jacobsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Jacobsen |
jacobsentransfer@gmail.com |
employee |
bancorft |
cuming |
Nebraska |
Jesse Jacobsen |
Austin moffatt |
Signed |
1103 |
2022-05-15 09:56 |
Anonymous (not verified) |
66.6.4.185 |
Christianson Trucking Inc., Owner Operator |
Proprietorship |
2134 Lakeview Lane Gary SD 57237 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-08 |
Christianson Trucking Inc., Paul Christianson Owner |
paulyc63@outlook.com |
Gary |
Deuel |
South Dakota |
Paul Christianson |
Nancy Christianson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christianson Trucking Inc., Paul Christianson Owner |
paulyc63@outlook.com |
Self |
Gary |
Deuel |
South Dakota |
Paul Christianson |
Nancy Christianson |
Signed |
1110 |
2022-05-17 11:17 |
Anonymous (not verified) |
64.33.230.163 |
Jed Hansen |
Proprietorship |
1626 Airport Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-17 |
Jed Douglas Hansen |
hangar.8@hotmail.com |
Clark |
Clark |
South Dakota |
Jed Hansen |
Jed Hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jed Hansen |
hangar.8@hotmail.com |
Proprietor |
Clark |
Clark |
South Dakota |
Jed Hansen |
Jed Hansen |
Signed |
1111 |
2022-05-17 11:18 |
Anonymous (not verified) |
64.33.230.163 |
Jed Hansen |
Proprietorship |
1626 Airport Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-17 |
Jed Douglas Hansen |
hangar.8@hotmail.com |
Clark |
Clark |
South Dakota |
Jed Hansen |
Jed Hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jed Hansen |
hangar.8@hotmail.com |
Proprietor |
Clark |
Clark |
South Dakota |
Jed Hansen |
Jed Hansen |
Signed |
1242 |
2022-08-03 14:53 |
Anonymous (not verified) |
107.141.197.247 |
Hygieia Stainless Solutions LLC |
Limited Liability Company |
2200 Blairsferry Crossing 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-03 |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
self |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
2223 |
2024-05-14 16:16 |
Anonymous (not verified) |
94.188.205.168 |
Test |
Proprietorship |
test |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-14 |
Test User |
aaron.staker@dia.iowa.gov |
Test |
Test |
Test |
Test Witness |
Test Witness 2 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Testing |
aaron.staker@dia.iowa.gov |
Testing |
Testing |
Testing |
Testing |
Testing Witness 1 |
Testing Witness 2 |
Signed |
176 |
2020-06-07 08:23 |
Anonymous (not verified) |
174.16.51.128 |
TrueFood LLC |
Limited Liability Company |
2055 Nature Ave Stanton IA 51573 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-24 |
Brian Barkman |
brian.barkman@truefood.farm |
Georgetown |
Williamson |
Texas |
Wanda Barkman |
Chelsea Church |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Barkman |
brian.barkman@truefood.farm |
TrueFood LLC is owned by agent |
Stanton |
Montgomery |
IA |
Wanda Barkman |
Chelsea Church |
Signed |
201 |
2020-07-09 11:07 |
Anonymous (not verified) |
167.142.98.40 |
Brock Chisum |
Proprietorship |
369 Wise Rd., Decatur, TX76234 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-09 |
Brock Chisum |
bchisum@hotmail.com |
Decatur, TX |
Wise |
Texas |
Lakota Larson |
Ryan Stott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brock Chisum |
bchisum@hotmail.com |
Self |
Decatur |
Wise |
Texas |
Lakota Larson |
Ryan Stott |
Signed |
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 |
1281 |
2022-08-24 11:06 |
Anonymous (not verified) |
47.185.154.197 |
Zachary Bobo |
Proprietorship |
2116 Newport Dr. Flower Mound, Tx. 75028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-24 |
Zachary Bobo |
ryan.zac@yahoo.com |
Flower Mound |
Denton |
Texas |
Kieth Volquardsen |
Chris Ventimiglia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Bobo |
ryan.zac@yahoo.com |
Self |
Flower Mound |
Denton |
Texas |
Kieth Volquardsen |
Chris Ventimiglia |
Signed |
2001 |
2024-01-26 10:41 |
Anonymous (not verified) |
94.188.207.225 |
4 Sons Splicing & Activation |
Proprietorship |
13510 W Brazos Bend Dr, Needville, TX 77461-9525 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
John Kevin Steil |
foursons1990@steil.org |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Helen Frances Steil |
foursons1990@steil.org |
Spouse |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
200 |
2020-07-09 10:56 |
Anonymous (not verified) |
167.142.98.40 |
brian chisum |
Proprietorship |
168 c.r. 2007 valley view tx |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-09 |
brian chisum |
chisum413@gmail.com |
valley view |
cooke |
tx |
lakota larson |
john morland |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
brian chisum |
chisum413@gmail.com |
self |
valley view |
cooke |
tx |
lakota larson |
john morland |
Signed |
585 |
2021-07-25 20:07 |
Anonymous (not verified) |
75.162.247.154 |
CJNR Works, LLC |
Limited Liability Company |
17003 Bowdin Crest Drive, Cypress, Texas 77433 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-25 |
Christopher Ridgway |
christopherridgway@gmail.com |
Cypress |
Harris |
TX |
Sophia Ridgway |
Mitchel Monahan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Ridgway |
christopherridgway@gmail.com |
Self |
Cypress |
Harris |
TX |
Sophia Ridgway |
Mitchel Monahan |
Signed |
598 |
2021-08-06 19:04 |
Anonymous (not verified) |
107.77.208.84 |
Paul Adams |
Proprietorship |
914 Bayfield drive Denton TX 76209 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-06 |
Paul T Adams |
ptadams61@yahoo.com |
Denton |
Denton |
Tx |
Jeanie Moses |
Richard Moses |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul T Adams |
ptadams61@yahoo.com |
Friends |
Milan |
Rock Island |
Illinois |
Jeanie Moses |
Richard Moses |
Signed |
1556 |
2023-04-05 14:08 |
Anonymous (not verified) |
94.188.205.169 |
Capstone Staffing Solutions LLC |
Limited Liability Company |
315 E 5th St, STE 202, Waterloo, IA, 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-05 |
Peterson Munyasia |
pete@capstonestaffingsolutions.com |
Allen |
USA |
TX |
Daniel Mwangi |
Elizabeth Munene |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peterson Munyasia |
pete@capstonestaffingsolutions.com |
Owner |
Allen |
USA |
TX |
Daniel Mwangi |
Elizabeth Munene |
Signed |
1649 |
2023-05-16 11:37 |
Anonymous (not verified) |
94.188.205.175 |
DEL-TA RESOURCE STAFFING, LLC |
Limited Liability Company |
17735 pinyon lane, Dallas TX 75252 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-16 |
Solomon Solomon |
solomon@del-taresourcestaffing.com |
Dallas |
Dallas |
TX |
John Effang |
Eric Ijie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Registered Agents Inc 315 E 5th St, STE 202 |
agent@washingtonregisteredagent.com |
Owner |
Waterloo |
Waterloo |
IA |
John Effang |
Eric Ijie |
Signed |
1905 |
2023-11-13 21:35 |
Anonymous (not verified) |
94.188.205.167 |
Bartolo Lopez |
Limited Liability Company |
2404 cass st Fort Worth tx 76112 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-13 |
Bartolo Lopez |
bartololopez3737@gmail.com |
Fort Worth tx |
Tarrant county |
Tx |
Airan Zamudio |
Carlos Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bartolo Lopez |
bartololopez3737@mail.com |
Boss of the company |
Fort Worth |
Tarrant county |
Texas |
Airan Zamudio |
Carlos lopez |
Signed |
11 |
2019-12-17 19:46 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Louis I. Maxwell |
brockbrooke2463@yahoo.com |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Louis Maxwell |
brockbrooke2463@yahoo.com |
Owner |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
12 |
2019-12-17 19:54 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Brock A Maxwell |
brock246393@gmail.com |
Des Moines |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brock A Maxwell |
brock246393@gmail.com |
Owner |
Des Moines |
POlK |
Iowa |
Yvonne Ginther |
Hope Winegardner |
Signed |
16 |
2019-12-31 08:54 |
Anonymous (not verified) |
70.184.208.208 |
J & D Transportation |
Proprietorship |
1125 Lew Ross Road Council Bluffs, IA 51501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Clarence Cecil Stogdill |
jack@jdmmtrucking.com |
Council Bluffs |
Iowa |
United States |
Mickey Jerome Stogdill |
Laurie Jo Stogdill |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clarence Cecil Stogdill |
jack@jdmmtrucking.com |
owner-same person |
Council Bluffs |
Iowa |
United States |
Mickey Jerome Stogdill |
Laurie Jo Stogdill |
Signed |
19 |
2019-12-31 16:29 |
Anonymous (not verified) |
172.58.83.45 |
A.M. Tile |
Proprietorship |
3824 122nd st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Amar Music |
amarmusic01@gmail.com |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amar Music |
amarmusic01@gmail.com |
Owner |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
20 |
2019-12-31 16:36 |
Anonymous (not verified) |
172.58.83.45 |
A.M. Tile |
Proprietorship |
3824 122nd st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Amar Music |
amarmusic01@gmail.com |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Omer Okic |
ultimate.exteriors@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Sefik Music |
Amara Crncevic |
Signed |
24 |
2020-01-03 12:41 |
Anonymous (not verified) |
63.152.13.239 |
Eden Plumbing LLC TJ Eden |
Limited Liability Company |
502 Packwaukee Street New Hartford, IA 50660 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-03 |
TJ Eden |
edentj@aol.com |
New Hartford |
IA |
United States |
Ann Robinson |
Nate Schmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PDCM Insurance- Nate Schmidt |
NSCHMIDT@PDCM.COM |
Member |
New Hartford |
Butler |
Iowa |
Ann Robinson |
Nate Schmidt |
Signed |
53 |
2020-02-06 11:09 |
Anonymous (not verified) |
65.100.22.228 |
Bostian Captioning Service, Inc. |
Proprietorship |
712 8th Avenue NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-06 |
Dana Bostian |
danabostian@msn.com |
Oelwein |
IA |
United States |
Lynne Koch |
Billie Winters |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dana Bostian |
danabostian@msn.com |
President of Proprietorship |
Oelwein |
IA |
United States |
Lynne Koch |
Billie Winters |
Signed |
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 |
62 |
2020-02-17 06:55 |
Anonymous (not verified) |
173.31.111.29 |
Pa's Construction LLC |
Limited Liability Company |
2350 Glass Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-17 |
Gregory Daniel Saunders |
gsaunders.pas@gmail.com |
CEDAR RAPIDS |
IOWA |
United States |
Laura Sturm |
Chad Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Walt Cheney |
Mike Broghammer |
Signed |
103 |
2020-03-25 11:48 |
Anonymous (not verified) |
174.250.52.2 |
ReFormin' Homes |
Proprietorship |
7740 NW 16th Street, Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-25 |
Martin Samuel Ledy |
reforminhomes@gmail.com |
Ankeny |
Iowa |
United States |
Timothy Allen Raynard |
Nicholas Paul Curtis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Samuel Ledy |
reforminhomes@gmail.com |
Same Person |
Ankeny |
Iowa |
United States |
Timothy Allen Raynard |
Nicholas Paul Curtis |
Signed |
108 |
2020-04-01 16:50 |
Anonymous (not verified) |
206.72.23.71 |
Heartland Renovations, LLC |
Limited Liability Company |
50253 290th Street, Kelley, IA 50134 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-01 |
Troy Van Maaren |
almostanything2@gmail.com |
Kelley |
Iowa |
United States |
Tammy J Reid |
Todd L Greenslit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Van Maaren |
almostanything2@gmail.com |
Member |
Kelley |
Story |
Iowa |
Tammy J Reid |
Todd L Greenslit |
Signed |
132 |
2020-04-27 17:26 |
Anonymous (not verified) |
73.94.97.93 |
Kota Construction |
Limited Liability Company |
52 SE Pembrooke Ln |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Dakota Beaulieu |
cody.b@buildwithkota.com |
Waukee |
IA |
United States |
Kyli Torkelson |
Koray Furrow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakota Beaulieu |
cody.b@buildwithkota.com |
Self |
Waukee |
Dallas |
Iowa |
Kyli Torkelson |
Koray Furrow |
Signed |
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 |
146 |
2020-05-01 05:34 |
Anonymous (not verified) |
174.217.5.175 |
Five Nail Services |
Limited Liability Company |
32379 162nd Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-01 |
Ralph Chiodo |
rchiodo2@gmail.com |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ralph Chiodo |
rchiodo2@gmail.com |
Self |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
155 |
2020-05-12 17:03 |
Anonymous (not verified) |
173.17.184.241 |
Shelly Whalen |
Proprietorship |
1625 Darby Dr Waterloo IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-12 |
Shelly Whalen |
swhalen90@hotmail.com |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelly Whalen |
swhalen90@hotmail.com |
self employed |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
162 |
2020-05-19 15:03 |
Anonymous (not verified) |
67.212.114.80 |
Collum Plumbing, LLC |
Limited Liability Company |
610 West 20th Street, Cedar Falls, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Stephen Collum |
collumplumbing@cfu.net |
Cedar Falls |
Iowa |
United States |
Mike Thode |
Linda Thode |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Collum |
collumplumbing@cfu.net |
Member of LLC |
Cedar Falls |
Black Hawk |
Iowa |
Mike Thode |
Linda Thode |
Signed |
182 |
2020-06-11 14:18 |
Anonymous (not verified) |
173.29.64.73 |
Diamond Builders of Davenport INC |
Proprietorship |
14358 275th St, Long grove, IA 52756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
Paula Woods |
paulawoods@diamond-builders.com |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Green |
tyler@porterinsuranceinc.com |
Insurance Agent |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
183 |
2020-06-12 08:23 |
Anonymous (not verified) |
107.77.173.7 |
A&W Marble & Tile |
Proprietorship |
5624 Sw 5Th Pl |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Wayne A Yergy |
wyergy@gmail.com |
Des Moines |
IA |
United States |
Michael L Smith |
Guy B Chaney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wayne Yergy |
wyergy@gmail.com |
Self |
Des Moines |
IA |
United States |
Michael L Smith |
Guy B Chaney |
Signed |
189 |
2020-06-16 16:24 |
Anonymous (not verified) |
173.28.58.2 |
Perry Engel |
Proprietorship |
140 2nd Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Perry Engel |
HRSolutionsContracting@gmail.com |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perry Engel |
HRSolutionsContracting@gmail.com |
Self |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
204 |
2020-07-15 11:21 |
Anonymous (not verified) |
63.152.54.222 |
Tim Duggan |
Limited Liability Company |
1405 1st 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. |
2020-07-15 |
Timothy M Duggan |
tdc.inc30@gmail.com |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy M Duggan |
tdc.inc30@gmail.com |
President |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
205 |
2020-07-15 14:19 |
Anonymous (not verified) |
108.209.12.64 |
Sequoia integrative Medical Services |
Limited Liability Company |
1746 Paul 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. |
2020-07-15 |
Jennifer Christine VandenHeuvel |
jvandenheuvel@att.net |
Kaukauna |
WI |
United States |
David VandenHeuvel |
Pam Leplavy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jennifer Christine VandenHeuvel |
jvandenheuvel@att.net |
Owner |
Kaukauna |
WI |
United States |
David VandenHeuvel |
Pam Leplavy |
Signed |
212 |
2020-07-20 16:43 |
Anonymous (not verified) |
97.64.164.30 |
Bernard L. Gradoville D.D.S. |
Proprietorship |
2800 Ingersoll Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-20 |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
self |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |
247 |
2020-08-26 20:00 |
Anonymous (not verified) |
67.132.237.42 |
OPN Renovations LLC |
Limited Liability Company |
1721 63rd 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. |
2020-08-26 |
Haruko Nakata |
harunakata@hotmail.com |
Des Moines |
Iowa |
United States |
Monica Parra |
Oscar D Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Haruko Nakata |
harunakata@hotmail.com |
Single Member |
Des Moines |
Iowa |
United States |
Monica Parra |
Oscar D Perez |
Signed |
258 |
2020-09-15 13:14 |
Anonymous (not verified) |
50.83.182.140 |
Moyer Painting |
Proprietorship |
934 Norwood Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-15 |
jerome Moyer |
moyer_painting@live.com |
Norwalk |
IA |
United States |
Sally Moyer |
Adam Adams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jerome b moyer |
moyer_painting@live.com |
Self |
norwalk |
IA |
United States |
sally moyer |
Adam Adams |
Signed |
273 |
2020-10-05 13:57 |
Anonymous (not verified) |
173.30.54.139 |
Jackson Exteriors |
Proprietorship |
705 Cherry Avenue Woodward,ia 50276 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-05 |
Lucas Jackson |
ljajackson41977@gmail.com |
Woodward |
IA |
United States |
Cody Roth |
Dustin Perry |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Jackson |
ljajackson41977@gmail.com |
Owner |
Woodward |
Dallas |
United States |
Cody Roth |
Dustin perry |
Signed |
291 |
2020-10-25 11:06 |
Anonymous (not verified) |
208.126.69.94 |
self-employed |
Proprietorship |
PO Box 15, 430 E. Iowa St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-25 |
Steven Fisher |
fishersjk@gmail.com |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Fisher |
fishersjk@gmail.com |
same person |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
292 |
2020-10-27 18:15 |
Anonymous (not verified) |
173.19.162.248 |
John Lass |
Limited Liability Company |
6025 SE 16TH CT |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-27 |
John Lass |
johnwlass@gmail.com |
Des Moines |
IA |
United States |
Dawn Lass |
Gordon Lamp Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Lass |
johnwlass@gmail.com |
self |
Des Moines |
IA |
United States |
Dawn Lass |
Gordon Lamp Jr |
Signed |
329 |
2020-12-01 10:02 |
Anonymous (not verified) |
74.84.125.43 |
BRAINARD ROOFING & CONSTRUCTION COMPANY |
Limited Liability Company |
4 South Ross St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Cody Brainard |
brainardrcc2020@gmail.com |
Farmersburg |
Clayton |
United States |
Dave Moellers |
Jordan Cannon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Brainard |
brainardrcc2020@gmail.com |
I am the authorized agent & employer |
Farmersburg |
IA |
United States |
Dave Moellers |
Jordan Cannon |
Signed |
330 |
2020-12-03 08:11 |
Anonymous (not verified) |
208.126.61.46 |
Hometown Comfort Heating & Cooling, LLC. |
Limited Liability Company |
1855 280th St. Webster City, Ia. 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-03 |
Mason Ormesher |
hometowncomfortia@gmail.com |
Webster City |
IA |
United States |
Kylee Ormesher |
Karen Ostrem |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Ormesher |
hometowncomfortia@gmail.com |
Owner |
Webster City |
Hamilton |
Iowa |
Kylee Ormesher |
Karen Ostem |
Signed |
333 |
2020-12-05 08:57 |
Anonymous (not verified) |
173.25.143.97 |
Groen Pediatric Consulting |
Limited Liability Company |
1206 NE 31ST ST Ankeny, IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Amy Groen |
dramygroen@yahoo.com |
Ankeny |
Iowa |
United States |
Daniel Martin |
Anita Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amy Groen |
dramygroen@yahoo.com |
self |
Ankeny |
Iowa |
United States |
Kay Martin |
Priscilla Putzier |
Signed |
346 |
2020-12-31 10:39 |
Anonymous (not verified) |
66.129.217.166 |
GIL Construction, LLC |
Limited Liability Company |
3107 M & W Crl, Muscatine, IA 52761 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-20 |
Lisseth Melendez Gil |
chonrosales88@gmail.com |
Muscatine |
Iowa |
United States |
Donis Medina |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Melendez Gil |
chonrosales88@gmail.com |
Owner |
Muscatine |
Iowa |
United States |
Donis Medina |
Anthony Johnson |
Signed |
347 |
2020-12-31 13:44 |
Anonymous (not verified) |
66.129.217.166 |
Issis Melissa Nunez |
Proprietorship |
2128 S Riverside Dr. Trl 57, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Issis Melissa Nunez |
tonypauljohnson@yahoo.com |
Iowa City |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Issis Melissa Nunez |
tonypauljohnson@yahoo.com |
Owner |
Iowa City |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
348 |
2020-12-31 14:09 |
Anonymous (not verified) |
66.129.217.166 |
Premier Plus LLC |
Limited Liability Company |
1930 St Andrews Crt NE, Suite A, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Cerby Newton |
tonypauljohnson@yahoo.com |
Cedar Rapids |
IA |
United States |
Olvin Lanza |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cerby Newton |
tonypauljohnson@yahoo.com |
Owner |
Cedar Rapids |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
360 |
2021-01-12 12:08 |
Anonymous (not verified) |
75.162.189.102 |
Super Green Plus Llc |
Limited Liability Company |
3020 SE 5th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-12 |
Damon Berry |
theatvfan@gmail.com |
Des Moines |
IA |
United States |
Naki Brown |
Nakima Brown |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Super Green Plus |
theatvfan@gmail.com |
owner |
Des Moines |
IA |
United States |
Naki Brown |
Nakima Brown |
Signed |
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 |
366 |
2021-01-18 18:32 |
Anonymous (not verified) |
75.162.57.214 |
Affordable Exteriors, LLC |
Limited Liability Company |
802 east COUNTY LINE RD #57 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-18 |
Destiny Moses |
Info@mktdsm.com |
DES MOINES |
IA |
United States |
Miguel Angel Garcia Ramirez |
Nelly Bekker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Destiny Moses |
Info@mktdsm.com |
owner |
DES MOINES |
IA |
United States |
Miguel Garcia |
Nellie Bekker |
Signed |
367 |
2021-01-21 14:18 |
Anonymous (not verified) |
107.117.168.117 |
1105 Wade St |
Proprietorship |
1105 WADE ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-03 |
Jose J Castillo |
Jonathancas782@gmail.com |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose J Castillo |
Jonathancas782@gmail.com |
Owner |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
374 |
2021-01-25 12:15 |
Anonymous (not verified) |
174.213.149.27 |
Vaughn Peyton |
Proprietorship |
3060 19th avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-25 |
Vaughn Peyton |
vaughnage173@hotmail.com |
Marion |
Iowa |
United States |
Ronald Bart Peyton |
Kristine Katherine Peyton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vaughn Peyton |
vaughnage173@hotmail.com |
Myself |
Marion |
Iowa |
United States |
Ronald Bart Peyton |
Kristine Katherine Peyton |
Signed |
378 |
2021-01-29 11:43 |
Anonymous (not verified) |
50.82.21.136 |
GRAPHIX MASTERS |
Limited Liability Company |
420 Hamilton St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-01-29 |
Klayton Karl Kirkpatrick |
klay@graphixmasters.us |
Ottumwa |
IA |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Klayton Kirkpatrick |
klay@graphixmasters.us |
Same |
Ottumwa |
Iowa |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
384 |
2021-02-03 20:36 |
Anonymous (not verified) |
66.129.217.166 |
GIL Construction, LLC |
Limited Liability Company |
3107 M & W Crl |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Muscatine |
Iowa |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Owner |
North Liberty |
IA |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
395 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
396 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
397 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
398 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
443 |
2021-03-22 13:22 |
Anonymous (not verified) |
167.127.218.244 |
Romero Carpentry |
Proprietorship |
2060 King Ave, Apt 19, 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. |
2021-03-22 |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Des moines |
Polk |
United States |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
464 |
2021-04-07 22:15 |
Anonymous (not verified) |
173.18.251.105 |
TEMPLEMAN LAWN CARE AND SNOW REMOVAL |
Proprietorship |
1612 Lomas Circle |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-07 |
TIM LEE Templeman |
nancytempleman@gmail.com |
Atlantic |
IA |
United States |
TARA JESSEN |
ALFRED WEDE |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
CULLEN AND ASSOCIATES |
tammy@cullenins.com |
Insurance agent |
Atlantic |
Cass |
Iowa |
Tara Jessen |
Alfred Wede |
Signed |
465 |
2021-04-07 22:24 |
Anonymous (not verified) |
173.18.251.105 |
TEMPLEMAN LAWN CARE |
Proprietorship |
1612 Lomas Cr. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-01 |
Tim Lee Templemn |
nancytempleman@gmail.com |
Atlantic |
Iowa |
United States |
Tara Jessen |
Alfred Wede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Lee Templeman |
nancytempleman@gmail.com |
self |
Atlantic |
Iowa |
Iowa |
Tara Jessen |
Alfred Wede |
Signed |
467 |
2021-04-10 12:21 |
Anonymous (not verified) |
24.252.54.168 |
Dave and Nancy Preucil Inc. |
Proprietorship |
13585 Clearview Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-10 |
Domenico Zurini II |
davesspeedwaydz@gmail.com |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbi Zurini |
bzurini@gmail.com |
Wife |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
482 |
2021-04-14 21:21 |
Anonymous (not verified) |
98.17.35.5 |
K3 Recycling LLC |
Limited Liability Company |
14801 180th Ave, Milo, IA 50166 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-14 |
Charles Raymond Kappelman |
charliekappelman@yahoo.com |
MILO |
Warren |
United States |
Ryan Matthew Kappelman |
John Allen Bahr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
K3 Recycling LLC |
charliekappelman@yahoo.com |
Co-owner |
Milo |
Warren |
Iowa |
Ryan Matthew Kappelman |
John Allen Bahr |
Signed |
496 |
2021-04-23 12:48 |
Anonymous (not verified) |
173.29.190.18 |
A+ Roofing and Siding Co |
Proprietorship |
1636 15th St Pl, Moline, IL 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-22 |
SHAWN HICKS |
APLUSROOFINGQCA@YAHOO.COM |
Milan |
IL |
United States |
deena hicks |
Mike Chandler |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
SHAWN HICKS |
APLUSROOFINGQCA@YAHOO.COM |
SELF/OWNER |
Milan |
IL |
United States |
deena hicks |
Mike Chandler |
Signed |
511 |
2021-05-10 17:53 |
Anonymous (not verified) |
173.24.231.27 |
QSC Snow Removal |
Proprietorship |
1211 Carroll Boone IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Vincent A Kaylor |
phenox32@gmail.com |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vincent A Kaylor |
phenox32@gmail.com |
self |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
541 |
2021-06-15 07:04 |
Anonymous (not verified) |
63.224.181.101 |
Schultes Horticulture and Landscape LLC |
Limited Liability Company |
1444 42nd 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. |
2021-06-15 |
Josh Schultes |
schulteshort@gmail.com |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Schultes |
schulteshort@gmail.com |
Self |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
548 |
2021-06-24 22:08 |
Anonymous (not verified) |
173.31.28.69 |
Brown's Window Cleaning +PLUS |
Proprietorship |
700 11th Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-24 |
Lawrence Brown |
brownswindowcleaningplus@gmail.com |
Altoona |
Iowa |
United States |
Jason Alderman |
Colette Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lawrence Brown |
brownswindowcleaningplus@gmail.com |
Self |
Altoona |
Iowa |
United States |
Jason Alderman |
Colette Evans |
Signed |
563 |
2021-07-08 12:16 |
Anonymous (not verified) |
173.17.250.209 |
Forest Avenue Outreach |
Limited Liability Company |
1600 6th Ave DSM IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-08 |
Maya Bromolson |
maya@goodvibesmovement.org |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maya Bromolson |
maya@goodvibesmovement.org |
Executive Director |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
565 |
2021-07-08 13:42 |
Anonymous (not verified) |
173.25.132.255 |
Communications Construction Services LLC |
Limited Liability Company |
1315 East 38th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-08 |
John McCann Jr |
communicationconstructionllc@gmail.com |
Des Moines |
IA |
United States |
Laura McCann |
David Garza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura McCann |
communicationconstructionllc@gmail.com |
spouse |
Des Moines |
IA |
United States |
John J McCann Jr |
David Christopher Garza III |
Signed |
569 |
2021-07-09 12:18 |
Anonymous (not verified) |
173.17.250.209 |
Forest Ave Outreach dba Good Vibes Movement |
Limited Liability Company |
1600 6th Ave DSM IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-09 |
Ben Spellman |
ben@goodvibesmovement.org |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maya Bromolson |
maya@goodvibesmovement.org |
Executive Director |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
571 |
2021-07-12 09:51 |
Anonymous (not verified) |
67.55.237.31 |
Steve Vogel |
Proprietorship |
314 NE 2ND ST. Panora, Iowa 50216-2020 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-12 |
Steve Vogel |
thevogels@netins.net |
PANORA |
Guthrie |
United States |
Diana Vogel |
Adam Vogel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Vogel |
thevogels@netins.net |
Self |
PANORA |
Guthrie |
Iowa |
Diana Vogel |
Adam Vogel |
Signed |
573 |
2021-07-14 09:12 |
Anonymous (not verified) |
166.181.83.201 |
Dustin Demoss |
Proprietorship |
407 mechanic 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. |
2021-07-13 |
Dustin Michael DeMoss |
dustindemoss14@gmail.com |
Monmouth |
Iowa |
United States |
Jake |
Jake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Michael DeMoss |
dustindemoss14@gmail.com |
Idk |
Monmouth |
Iowa |
United States |
Jake |
Jake |
Signed |
583 |
2021-07-23 12:37 |
Anonymous (not verified) |
206.72.45.27 |
S&L Finishers LLC |
Limited Liability Company |
307 N 5th Street Mallard Ia 50562 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-23 |
Luke AKRIDGE |
akridgel@ncn.net |
Mallard |
Palo Alto |
United States |
Kennedy Origer |
Andy Wiita |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke AKRIDGE |
akridgel@ncn.net |
Owner |
MALLARD |
IA |
United States |
Kennedy Origer |
Andy Wiita |
Signed |
591 |
2021-07-29 16:42 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Dustin Fessler |
dustin@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Fessler |
dustin@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Adam Reth |
Signed |
592 |
2021-07-29 16:44 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Adam Reth |
adam@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Reth |
adam@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Dustin Fessler |
Signed |
602 |
2021-08-13 22:49 |
Anonymous (not verified) |
208.38.230.125 |
Granite & More |
Limited Liability Company |
4730, Tremont Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-14 |
Jin Chen |
clteam563@gmail.com |
Davenport |
IA |
United States |
Jin Chen |
Betty Song |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hong Le |
clteam563@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Jin Chen |
Betty Song |
Signed |
603 |
2021-08-14 09:39 |
Anonymous (not verified) |
173.20.168.51 |
Leaf Filter |
Proprietorship |
3060 Southeast Grimes Boulevard |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-08-14 |
Francisco Salgado |
fsalgado1989@gmail.com |
Perry |
IA |
United States |
Wendy Asturias |
Susana Romero |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Leaf Filter |
macosta@leafhome.com |
none |
Grimes |
Polk |
Iowa |
Wendy Asturias |
Susana Romero |
Signed |
604 |
2021-08-14 11:18 |
Anonymous (not verified) |
69.54.119.134 |
Robert Curry |
Limited Liability Company |
10759 S 96th Ave W Prairie City IA 50228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-14 |
Bob Curry |
Gardengal4205@gmail.com |
Prairie City |
IA |
United States |
Megan Irwin |
Rob Irwin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Curry |
Gardengal4205@gmail.com |
Self |
Prairie City |
IA |
United States |
Megan Irwin |
Rob Irwin |
Signed |
615 |
2021-08-20 16:22 |
Anonymous (not verified) |
50.81.152.147 |
CPIA Home Specialists LLC |
Limited Liability Company |
1214 13th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
623 |
2021-08-30 15:03 |
Anonymous (not verified) |
174.198.77.231 |
Joe Dawson |
Proprietorship |
1088, Dogwood Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-30 |
Joe R Dawson |
joerdawson@gmail.com |
Coon Rapids |
IA |
United States |
Linda Doran |
Megan Specht |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Joe R Dawson |
joerdawson@gmail.com |
Owner |
Coon Rapids |
IA |
United States |
Linda Doran |
Megan Specht |
Signed |
650 |
2021-09-22 20:46 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services |
Limited Liability Company |
6285 n 67 ave w baxter iowa 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
651 |
2021-09-22 21:05 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services LLC |
Limited Liability Company |
6285 n 67 ave w. BAXTER IOWA 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
653 |
2021-09-23 15:03 |
Anonymous (not verified) |
72.46.189.33 |
Feldkamp Farms Inc |
Partnership |
5382 170th St Sibley IA 51249 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-23 |
Harold P Feldkamp |
joan@ellerbroekandassociates.com |
Sibley |
IA |
United States |
Wade Ellerbroek Jr |
Joan Wallace |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Wade Ellerbroek Jr |
WADE@ELLERBROEKANDASSOCIATES.COM |
Agent only |
Sibley |
IA |
United States |
Wade Ellerbroek Jr |
Joan Wallace |
Signed |
659 |
2021-09-28 11:02 |
Anonymous (not verified) |
172.58.83.48 |
Sean Goodwin |
Limited Liability Company |
8843 primrose lane Clive IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-28 |
Sean Goodwin |
simplemanmx@gmail.com |
Clive |
IA |
United States |
Kaitlyn meier |
Tina meier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Goodwin |
simplemanmx@gmail.com |
Self |
Clive |
Polk |
Iowa |
Kaitlyn meier |
Tina meier |
Signed |
667 |
2021-10-11 19:33 |
Anonymous (not verified) |
104.166.240.24 |
FS Custom Flooring |
Limited Liability Company |
5729 NW 92nd street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-11 |
Filip Sakanovic |
filip@fscustomflooring.com |
Johnston |
IA |
United States |
Senad Sakanovic |
Filip Sakanovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
FS Tiling and Ceramics |
filip@fscustomflooring.com |
N/A |
Johnston |
IA |
United States |
Senad Sakanovic |
Filip Sakanovic |
Signed |
677 |
2021-10-18 11:09 |
Anonymous (not verified) |
69.18.40.109 |
MR&E,llc |
Limited Liability Company |
2501 Summer St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-18 |
Marcie R Gaylord |
avisburlington@hotmail.com |
Fort Madison |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcie Bollin Gaylord |
avisburlington@hotmail.com |
President |
FORT MADISON |
Lee |
Iowa |
Kim Delap |
Teri Coleman |
Signed |
678 |
2021-10-18 11:26 |
Anonymous (not verified) |
69.18.40.109 |
MR&E,llc |
Limited Liability Company |
2501 Summer St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-18 |
Linda Hunter |
whitandpayt@gmail.com |
Burlington |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcie Bollin Gaylord |
avisburlington@hotmail.com |
President |
FORT MADISON |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
680 |
2021-10-18 13:58 |
Anonymous (not verified) |
166.181.86.88 |
Gerald Jerome |
Proprietorship |
2668 Wapsi Ridge Dr. Walker, IA 52352 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-18 |
Gerald Jerome |
geraldjerome373@ymail.com |
Walker |
IA |
United States |
Benjamin J Barkalow |
James M. Barkalow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerald Jerome |
geraldjerome373@ymail.com |
Self employed |
Walker |
Linn |
Iowa |
Benjamin J Barkalow |
James M Barkalow |
Signed |
683 |
2021-10-20 09:39 |
Anonymous (not verified) |
173.23.253.122 |
Superior Floors |
Limited Liability Company |
704 41st Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-20 |
Ron Shannon |
ronshannon3831@gmail.com |
West Des Moines |
IA |
United States |
Virginia Shannon |
Virginia Shannon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Shannon |
ronshannon3831@gmail.com |
Self |
West Des Moines |
IA |
United States |
Virginia Shannon |
Virginia Shannon |
Signed |
689 |
2021-10-25 14:38 |
Anonymous (not verified) |
107.197.114.249 |
Brookstin Flooring LLC |
Limited Liability Company |
1702 Brown Deer Rd Coralville IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-10-25 |
Richard T Klemesrud |
rickklemesrud@gmail.com |
CORALVILLE |
IA |
United States |
Brian Woods |
Sherry Woods |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Richard T Klemesrud |
rickklemesrud@gmail.com |
Myself / Owner |
CORALVILLE |
IA |
United States |
Brian Woods |
Sherry Woods |
Signed |
696 |
2021-10-28 10:33 |
Anonymous (not verified) |
173.18.85.215 |
Saunders Construction |
Proprietorship |
7304 SW 14th St Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-28 |
Charles A Saunders |
charlessaunders901@gmail.com |
Des Moines |
IA |
United States |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Saunders |
charlessaunders901@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
699 |
2021-10-28 21:28 |
Anonymous (not verified) |
75.162.104.116 |
Hild Construction, LLC |
Limited Liability Company |
6439 NE 5th 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. |
2021-10-28 |
Jason Hild |
dirtsailor133@gmail.com |
Pleasant Hill |
Iowa |
United States |
Scott Dart |
Michael Kramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Hild |
dirtsailor133@gmail.com |
Self |
Pleasant Hill |
Polk |
United States |
Scott Dart |
Michael Kramer |
Signed |
730 |
2021-11-08 14:58 |
Anonymous (not verified) |
97.64.139.42 |
JZ INC |
Limited Liability Company |
2509 Ne 10th CT Grimes Iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-08 |
James Zastrow |
Zastrow74@gmail.com |
Grimes |
Iowa |
United States |
Kevan Wiggins |
Jeremy Holmes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Zastrow |
zastrow74@gmail.com |
Self |
grimes |
polk |
iowa |
Kevan Wiggins |
Jeremy Holmes |
Signed |
760 |
2021-11-21 16:31 |
Anonymous (not verified) |
107.77.206.216 |
Jacob Odean |
Limited Liability Company |
6634 Lorton CT. Davenport IA 52807 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-21 |
Jacob James Odean |
jodean5725@gmail.com |
DAVENPORT |
IA |
United States |
James Odean |
Vickie Odean |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob James Odean |
jodean5725@gmail.com |
Same |
DAVENPORT |
SCOTT |
United States |
James Odean |
Vickie Odean |
Signed |
773 |
2021-11-24 14:48 |
Anonymous (not verified) |
24.149.18.237 |
The Ragged Edge Art Bar and Gallery |
Limited Liability Company |
504 Bluff Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-24 |
Kendra Wohlert |
kwohlert43@gmail.com |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendra Wohlert |
kwohlert43@gmail.com |
self |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
784 |
2021-12-09 09:03 |
Anonymous (not verified) |
97.64.139.42 |
JZ INC |
Limited Liability Company |
2509 Ne 10th CT Grimes Iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-08 |
James Scott Zastrow |
Zastrow74@gmail.com |
Grimes |
IA |
United States |
NIcole Zastrow |
Kevan Wiggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James scott Zastrow |
loffredon@aol.com |
Self |
Grimes |
IA |
United States |
nicole zastrow |
Kevan wiggins |
Signed |
787 |
2021-12-13 16:15 |
Anonymous (not verified) |
64.5.77.84 |
Heartland Counseling Services |
Limited Liability Company |
813 Flindt 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. |
2021-11-05 |
Kathleen Ruscitto |
info@heartlandcounselingia.com |
STORM LAKE |
Iowa |
United States |
David Kirk |
Michael Robertson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathleen Ruscitto |
info@heartlandcounselingia.com |
Self/Owner |
STORM LAKE |
Iowa |
United States |
David Kirk |
Michael Robertson |
Signed |
813 |
2021-12-27 10:18 |
Anonymous (not verified) |
172.58.84.252 |
LLC |
Partnership |
866 40th Ave Bettendorf, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-23 |
Kimberly Anne Liggitt |
kliggitt25@gmail.com |
Rock Island |
IL |
United States |
Suzanne Jeanette Liggitt |
Christie Marie Liggitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
codydunbar@leaffilter.com |
Manager |
866 40th Ave Bettendorf ia 52722 |
Scott County |
IA |
Jordan nisiewicz |
Cody Dunbar |
Signed |
815 |
2021-12-28 12:29 |
Anonymous (not verified) |
173.29.239.122 |
Comtek, Inc. |
Proprietorship |
3702 NW 13th St. Ankeny, Iowa 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-28 |
Micheal D. Qualley |
mqcomtek@gmail.com |
ANKENY |
IA |
United States |
Jacque Blackman |
Jeffery Keipper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacque Blackman |
jblackman@grimesfinancialgroup.com |
client |
Grimes |
Polk |
Iowa |
Jacque Blackman |
Jeffery Keipper |
Signed |
825 |
2022-01-06 21:02 |
Anonymous (not verified) |
174.213.145.18 |
Two Brothers Tile llc |
Proprietorship |
1244 72nd St Windsor heights ia 50324 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-06 |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Owner |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
842 |
2022-01-17 16:29 |
Anonymous (not verified) |
172.58.87.164 |
The Green Boys |
Limited Liability Company |
55 Southeast Windfield Parkway |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-17 |
Emilio Belismelis |
emiliobelismelis87@gmail.com |
Waukee |
IA |
United States |
Lorena Belismelis |
Lorena Belismelis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
The Green Boys |
emiliobelismelis87@gmail.com |
Owner |
Waukee |
IA |
United States |
Emilo Belismelis |
Maria Belismelis |
Signed |
852 |
2022-01-21 15:52 |
Anonymous (not verified) |
75.162.3.62 |
Alternative Interventions, LLC |
Limited Liability Company |
3116 Ingersoll, #4 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-21 |
Carla Olson |
altint3116@gmail.com |
West Des Moines |
Dallas |
United States |
Michelle Grandstaff |
Alexandra Killinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CARLA OLSON |
altint3116@gmail.com |
Owner |
DES MOINES |
Polk |
United States |
Michelle Grandstaff |
Alexandra Killinger |
Signed |
854 |
2022-01-24 19:59 |
Anonymous (not verified) |
217.180.228.216 |
Hansen Installations |
Limited Liability Company |
109 NW Calista Ct. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-24 |
Brian D Hansen |
bdhansen33@gmail.com |
Grimes |
IA |
United States |
Laurie Mills |
Jaiden Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian D Hansen |
bdhansen33@gmail.com |
Self |
Grimes |
IA |
United States |
Laurie Mills |
Jaiden Nelson |
Signed |
855 |
2022-01-26 10:39 |
Anonymous (not verified) |
209.152.66.250 |
Robert L Stutzman |
Limited Liability Company |
33784 Hwy 22 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-26 |
Robert L Stutzman |
bnbstutzman@gmail.com |
Keota |
Iowa |
United States |
Dasha Hesseltine |
Janette Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sandra Stutzman |
iafarmgirl90@gmail.com |
Daughter |
Keota |
Iowa |
United States |
Dasha Hesseltine |
Janette Miller |
Signed |
858 |
2022-01-27 08:06 |
Anonymous (not verified) |
75.162.81.119 |
MR Custom Tile & Flooring LLC |
Limited Liability Company |
14390 Newbold Street, Indianola, IA, 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Matthew Royer |
royer20@yahoo.com |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Royer |
royer20@yahoo.com |
Myself |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
864 |
2022-01-27 12:50 |
Anonymous (not verified) |
67.55.155.207 |
Chamra Farms |
Limited Liability Company |
3031 215 th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Andy Chamra |
apchamra@gmail.com |
Rose Hill |
Iowa |
United States |
Steve Weller |
Connie VanKlootwyk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Weller |
steve.weller@insurancestationinc.com |
Agent |
OSKALOOSA |
Iowa |
United States |
Andy Chamra |
Connie Van Klootwyk |
Signed |
865 |
2022-01-27 12:53 |
Anonymous (not verified) |
67.55.155.207 |
Chamra Farms |
Limited Liability Company |
3031 215 th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Roy Chamra |
apchamra@gmail.com |
Rose Hill |
Iowa |
United States |
Steven Weller |
Connie VanKlootwyk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Weller |
steve.weller@insurancestationinc.com |
Agent |
OSKALOOSA |
Iowa |
United States |
Roy Chamra |
Connie Van Klootwyk |
Signed |
866 |
2022-01-27 19:15 |
Anonymous (not verified) |
199.66.15.25 |
Greg Cheno Services LLC |
Limited Liability Company |
203 N H St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Gregory Chenoweth |
gregcheno@gmail.com |
Indianola |
IA |
United States |
Rebecca Sue Abbott |
Gregory Blair Abbott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gregory J. Chenoweth |
gregcheno@gmail.com |
Same |
Indianola |
Warren |
Iowa |
Rebecca Sue Abbott |
Gregory Blair Abbott |
Signed |
879 |
2022-01-31 14:26 |
Anonymous (not verified) |
173.27.146.201 |
Premier Window Cleaning LLC |
Limited Liability Company |
420 E GRANGER AVE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-31 |
Frank Viola |
premierofiowa@gmail.com |
DES MOINES |
IA |
United States |
Ron Reynolds |
Chris Greco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frank Viola |
premierofiowa@gmail.com |
my self |
DES MOINES |
IA |
United States |
Ron Reynolds |
Chris Greco |
Signed |
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 |
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 |
951 |
2022-03-05 07:53 |
Anonymous (not verified) |
207.32.3.98 |
Larson Transport Systems |
Limited Liability Company |
3055 Maple Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-05 |
Spencer Larson |
spenlarson@gmail.com |
Forest City |
IA |
United States |
Mike Larson |
Sandy Larson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Larson |
spenlarson@gmail.com |
owner |
Forest City |
IA |
United States |
Mike Laron |
Sandy Larson |
Signed |
958 |
2022-03-08 20:17 |
Anonymous (not verified) |
50.82.39.158 |
Ramos Drywall |
Limited Liability Company |
1355 Ozark Ridge, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-03-08 |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
Coralville |
Iowa |
United States |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
N/A- Same Person |
Coralville |
Johnson County |
IA |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
966 |
2022-03-11 10:04 |
Anonymous (not verified) |
173.19.189.168 |
Steger Siding & Construction |
Limited Liability Company |
1020 25th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-11 |
Jared Steger |
jared.steger@gmail.com |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Steger |
jared.steger@gmail.com |
self |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
988 |
2022-03-21 10:40 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th Ave. S. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-20 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
N/A |
N/a |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Owner |
Clinton |
IA |
United States |
N/A |
N/A |
Signed |
989 |
2022-03-21 10:40 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th Ave. S. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-20 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
N/A |
N/a |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Owner |
Clinton |
IA |
United States |
N/A |
N/A |
Signed |
994 |
2022-03-22 12:19 |
Anonymous (not verified) |
75.162.125.176 |
performance painting llc |
Limited Liability Company |
4905 nw 4th street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-22 |
thomas lilly |
TLilly816@aol.com |
ankeny |
IOWA |
United States |
Sharon kay Gaulke |
Charles Thomas Cater |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Performance Painting LLC |
TLilly816@aol.com |
owner |
ankeny |
IOWA |
United States |
Sharon Kay Gaulke |
Charles Thomas Cater |
Signed |
1001 |
2022-03-23 10:37 |
Anonymous (not verified) |
104.201.100.158 |
Joel Jacobsen |
Proprietorship |
1337 S 7th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Joel Jacobsen |
jjacobsen@phillipsstafford.com |
Adel |
Iowa |
United States |
Luke Peterson |
Luke van Roekel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Jacobsen |
jjacobsen@phillipsstafford.com |
Self |
Adel |
Iowa |
United States |
Luke Peterson |
Luke Van Roekel |
Signed |
1003 |
2022-03-23 13:06 |
Anonymous (not verified) |
24.149.3.190 |
Thomas Wedmore |
Proprietorship |
200 State St, Ste 202G, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Cedar Falls |
IA |
United States |
Bradley Phillips |
Joshua Stafford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Self |
Reinbeck |
Grundy |
IA |
Bradley Phillips |
Joshua Stafford |
Signed |
1020 |
2022-03-29 16:53 |
Anonymous (not verified) |
207.32.60.144 |
J.A. Dahlhauser, Ltd. |
Proprietorship |
1741 Hwy. 7 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Jaylin A. Dahlhauser |
jaydahlhauser@gmail.com |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaylin A. DAhlhauser |
jaydahlhauser@gmail.com |
Owner |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
1034 |
2022-04-05 11:43 |
Anonymous (not verified) |
75.162.133.214 |
Riftworks Wood Manufactory |
Proprietorship |
3807 Adams Ave, Des moines, Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Bryan Siever |
bryan@siever.us |
Des Moines |
IA |
United States |
Cakeb Payne |
Tyler Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryan siever |
bryan@siever.us |
Business owner |
Des Moines |
IA |
United States |
Caleb Payne |
Tyler Anderson |
Signed |
1036 |
2022-04-06 10:22 |
Anonymous (not verified) |
67.212.111.166 |
Precision Painting |
Proprietorship |
507 Broad Street, Reinbeck Iowa 50669 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-06 |
Dan Bowser |
dbowser.precision.painting@gmail.com |
Reinbeck |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
1038 |
2022-04-11 09:43 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th Ave. S. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-11 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay County |
Missouri |
Roberto J Henrickson |
Cody Dunbar |
Signed |
1044 |
2022-04-13 09:11 |
Anonymous (not verified) |
166.181.81.114 |
Paul Wall Assemblies LLC |
Limited Liability Company |
38165 Belgian rd. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-04-13 |
Paul Carnicle |
paulcarnicle@yahoo.com |
Strawberry Point |
Iowa |
United States |
Alexander Gabriel Guthrie |
Sebastin Thompsin |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Paul Carnicle |
paulcarnicle@yahoo.com |
Partner |
Strawberry Point |
Iowa |
United States |
Alexander Gabriel Guthrie |
Sebastin Thompson |
Signed |
1049 |
2022-04-14 14:29 |
Anonymous (not verified) |
72.13.27.253 |
Gudenkauf Underground llc |
Limited Liability Company |
1840 275th St Manchester Ia., 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Self |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
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 |
1057 |
2022-04-18 12:53 |
Anonymous (not verified) |
204.16.59.10 |
Iowa’s Gutter Specialist LLC |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Heather Halverson |
Michael Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Heather Marie Halverson |
Michael Alexander Halverson |
Signed |
1058 |
2022-04-19 13:19 |
Anonymous (not verified) |
50.83.154.192 |
Property Maintenance Services of Iowa LLC |
Limited Liability Company |
PO Box 166 Low Moor IA 52757 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
Frederick Stewart |
curlyfry42000@yahoo.com |
LOW MOOR |
IA |
United States |
Irene R Stewart |
Derek S Jensen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frederick Lee Stewart |
zombiesby2012@gmail.com |
Owner |
Clinton |
IA |
United States |
Irene R Stewart |
Derek S Jensen |
Signed |
1067 |
2022-04-23 11:17 |
Anonymous (not verified) |
166.181.82.231 |
Black Squirrel Siding LLC. |
Limited Liability Partnership |
1512 north 1st ave 203s |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-23 |
Robby Bartosh |
zodzoey19@gmail.com |
Cedar Rapids |
IA |
United States |
Phoenix Bartosh |
Elijah Irish |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah Petsche |
Blacksquirrelsiding@gmail.com |
business partner |
coralville |
johnson |
iowa |
Phoenix Bartosh |
Elijah Irish |
Signed |
1072 |
2022-04-26 16:17 |
Anonymous (not verified) |
166.182.80.187 |
N & S Trucking Inc |
Limited Liability Company |
3061 170Th 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. |
2022-04-26 |
Steven Kirk Van Ommen |
Stevevo74@yahoo.com |
Riverside |
Iowa |
United States |
Steve Van Ommen |
Steve Van Ommen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Kirk Van Ommen |
Stevevo74@yahoo.com |
President |
Riverside |
IA |
United States |
Steve Van Ommen |
Steve Van Ommen |
Signed |
1082 |
2022-04-29 12:28 |
Anonymous (not verified) |
75.162.101.109 |
Jodi Trewet |
Proprietorship |
11920 NW 114th Ln Granger, IA 50109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-29 |
Jodi Trewet |
jtrewet@yahoo.com |
Granger |
IA |
United States |
Mark Trewet |
Tyler Trewet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jodi Trewet |
jtrewet@yahoo.com |
Same |
Granger |
Polk |
IA |
Mark Trewet |
Tyler Trewet |
Signed |
1087 |
2022-05-04 12:32 |
Anonymous (not verified) |
67.212.117.157 |
Polk's Lock Service, Inc. |
Limited Liability Partnership |
1504 College Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-04 |
Myron Piehl |
polkslockservice@gmail.com |
Cedar Falls |
IA |
United States |
Jonathon Illian |
Katrina Reyerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Myron John Piehl |
polkslockservice@gmail.com |
owner |
Cedar Falls |
IA |
United States |
Jonathan Illian |
Katrina Clair Reyerson |
Signed |
1092 |
2022-05-09 17:49 |
Anonymous (not verified) |
199.247.76.21 |
Mitchell Ellison |
Limited Liability Company |
906 Lakeshore Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-09 |
Mitchell Ellison |
Essential.ellison@gmail.com |
Lakeside |
Iowa |
United States |
Mitchell Ellison |
Mitchell Ellison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Ellison |
Essential.ellison@gmail.com |
Self |
Lakeside |
Iowa |
United States |
Mitchell Ellison |
Mitchell Ellison |
Signed |
1095 |
2022-05-12 13:20 |
Anonymous (not verified) |
173.31.29.53 |
Leaf cutter protection |
Limited Liability Company |
4146 East 23rd Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-05-12 |
Gideon Lagat |
gsaina78@gmail.com |
Des Moines |
IA |
United States |
Priscilla saina |
Cosmas nyaika |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark rond |
mbond@leaffilter.com |
Regional installation Manager |
Grimes |
Polk |
Iowa |
Priscilla saina |
Cosmas nyaika |
Signed |
1107 |
2022-05-16 15:28 |
Anonymous (not verified) |
64.33.230.163 |
hangar 8 spray service |
Limited Liability Company |
1626 airport dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
jed douglas hansen |
hangar.8@hotmail.com |
Clark |
South Dakota |
United States |
jed douglas hansen |
jed douglas hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jed douglas hansen |
hangar.8@hotmail.com |
contract |
Clark |
South Dakota |
United States |
Jed Hansen |
Jed Hansen |
Signed |