1360 |
2022-11-04 11:13 |
Anonymous (not verified) |
50.81.34.190 |
Rescue 365 Towing & Salvage |
Limited Liability Company |
2569 58th St Vinton, IA 52349 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-04 |
Tyler Schwartz |
rescue365@hotmail.com |
VAN HORNE |
Benton |
IA |
Tony Harmon |
Tracy Beitz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Schwartz |
rescue365@hotmail.com |
Self |
Van Horne |
Benton |
IA |
Tony Harmon |
Tracy Beitz |
Signed |
55 |
2020-02-07 15:14 |
Anonymous (not verified) |
204.153.176.73 |
J*M Fuels, LLC |
Limited Liability Company |
600 W Bremer Avenue, Waverly IA 50677 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-07 |
Matt Johnson |
mattjohnson7555@gmail.com |
Jackson TWP |
Butler |
Iowa |
Ty Burke |
Lori Frerichs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tylor Burke |
tburke@acceladvantage.com |
Agent |
Waverly |
IA |
United States |
Tony Pollastrini |
Lori Frerichs |
Signed |
1978 |
2024-01-08 13:28 |
Anonymous (not verified) |
94.188.205.167 |
TYREL GIBSON |
Proprietorship |
2004 CHICAGO AVE SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-08 |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
498 |
2021-04-27 12:54 |
Anonymous (not verified) |
173.31.147.225 |
TYREL KINKADE DBA: KINKADE CONSTRUCTION |
Proprietorship |
2289 165TH ST UNIT 10D |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-21 |
TYREL KINKADE |
hogtyd97@yahoo.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL KINKADE |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1859 |
2023-10-04 07:54 |
Anonymous (not verified) |
94.188.205.167 |
Pacheco Constructrion |
Limited Liability Company |
1614 Center Street, Des Moines IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-04 |
Ulises Pacheco |
info@pachecoconstruction.com |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ulises Pacheco |
info@pachecoconstruction.com |
Self |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
393 |
2021-02-11 12:36 |
Anonymous (not verified) |
173.21.130.224 |
Ashby Roofing |
Proprietorship |
3307 Clearwater dr Bettendorf |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-11 |
Thomas Ashby |
Tashby8@aol.com |
Bettendorf |
Scott |
Iowa |
Veronica Ashby |
Tommy Ashby |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
United Insurance Counslers |
Tashby8@aol.com |
owner |
Bettendorf |
Scott |
Iowa |
Veronica Ashby |
Tommy Ashby |
Signed |
1525 |
2023-03-20 15:28 |
Anonymous (not verified) |
94.188.205.174 |
Valentin Saucedo |
Proprietorship |
1811 W 5th St, Sioux City, IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-20 |
Valentin Saucedo |
sauceds20@gmail.com |
Sioux City |
Woodbury |
IA |
Jacob Goodin |
Kevin Small |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valentin Saucedo |
sauceds20@gmail.com |
Sole Prop |
Sioux City |
Woodbury |
IA |
Jacob Goodin |
Kevin Small |
Signed |
74 |
2020-02-24 15:00 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Gomez |
Liberty21424@gmail.com |
Des Moines |
Polk |
IA |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
75 |
2020-02-24 15:03 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Bucio |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
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 |
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 |
1150 |
2022-06-10 16:14 |
Anonymous (not verified) |
173.29.125.38 |
Vernon Tim McClain |
Limited Liability Company |
2717 Thompson ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-10 |
Vernon Tim McClain |
mcclainlawn@gmail.com |
Des Moines |
POlk |
Iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
vernon mcclain |
mcclainlawn@gmail.com |
business owner |
des moines |
polk |
iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
657 |
2021-09-27 13:55 |
Anonymous (not verified) |
167.142.136.87 |
Crosser Electric,Inc |
Partnership |
PO Box 204 Eldora, Iowa 50627 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-27 |
Marlyn D Crosser |
vhalvorsen@aol.com |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vicki Halvorsen |
vhalvorsen@aol.com |
Partner andf sec/treasurer |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
1976 |
2024-01-04 15:48 |
Anonymous (not verified) |
94.188.207.224 |
Brawdy Services |
Proprietorship |
7029 Prairie Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
Victor Brawdy |
heather.l.brawdy@gmail.com |
Urbandale |
Polk |
IA |
Summer Munoz |
Jennifer Wolters |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Brawdy |
vb69ia@gmail.com |
Self |
Urbandale |
Polk |
IA |
Summer Munox |
Jennifer Wolters |
Signed |
921 |
2022-02-17 12:38 |
Anonymous (not verified) |
173.22.55.191 |
Holzworth Land Company |
Limited Liability Company |
1730 All State Ct. Suite 100 West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Victor Holzworth |
holzconstruction@gmail.com |
Waukee |
Dallas |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Holzworth |
holzconstruction@gmail.com |
Owner |
West Des Moines |
Polk |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
922 |
2022-02-17 12:44 |
Anonymous (not verified) |
173.22.55.191 |
Red Rock Hunt Club |
Limited Liability Company |
1730 All State Ct. Suite 100 West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Victor Holzworth |
holzconstruction@gmail.com |
Waukee |
Dallas |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Holzworth |
holzconstruction@gmail.com |
Owner |
West Des Moines |
Polk |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
923 |
2022-02-17 12:49 |
Anonymous (not verified) |
173.22.55.191 |
Fat Bus |
Limited Liability Company |
1730 All State Ct. Suite 100 West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Victor Holzworth |
holzconstruction@gmail.com |
Waukee |
Dallas |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Holzworth |
holzconstruction@gmail.com |
Owner |
West Des Moines |
Polk |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
1497 |
2023-03-07 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Holzworth Land Company |
Limited Liability Company |
1730 All State Ct Suite 100 West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-03-07 |
Victor Holzworth |
holzconstruction@gmail.com |
West Des Moines |
Polk |
Iowa |
Reid Tamisiea |
Mariah Burgett |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Victor Holzworth |
holzconstruction@gmail.com |
Owner |
West Des Moines |
Polk |
iowa |
Reid Tamisea |
Mariah Burgett |
Signed |
658 |
2021-09-27 14:01 |
Anonymous (not verified) |
167.142.136.87 |
Crosser Electric, Inc |
Partnership |
PoBox 204 Eldora, Iowa 50627 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-27 |
Victoria Halvorsen |
vhalvorsen@aol.com |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victoria or Vicki Halvorsen |
vhalvorsen@aol.com |
Partner sec/treasure |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
1204 |
2022-07-14 11:59 |
Anonymous (not verified) |
107.1.252.41 |
International Drywall LLC. |
Limited Liability Company |
108 N 4th 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. |
2022-07-14 |
Victoria G Cervantes |
vic8.cervantes@gmail.com |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victoria G Cervantes |
Vic8.cervantes@gmail.com |
Self |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
73 |
2020-02-21 13:44 |
Anonymous (not verified) |
192.30.185.233 |
Viejos Masnry construction LLC |
Limited Liability Company |
1708 Villa Ave. Sioux City IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-13 |
Oscar Castro Ramirez |
veijosconstruction@gmail.com |
Sioux City |
Woodbury |
Iowa |
JEFFREY H MCCLINTOCK |
Nancy Fleming |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Viejos Masonry Construction LLC |
veijosconstruction@gmail.com |
Owner/President |
SIOUX CITY |
Woodbury |
Iowa |
Nancy Fleming |
Jeffrey Hugh McClintock |
Signed |
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 |
1977 |
2024-01-05 13:25 |
Anonymous (not verified) |
94.188.207.228 |
BOYOK BUILDS, LLC |
Limited Liability Company |
25395 140TH ST, SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-04 |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
322 |
2020-11-17 14:06 |
Anonymous (not verified) |
208.126.118.26 |
Wada Farms |
Limited Liability Company |
2428 270th st Grand Mound, IA 52751 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-17 |
Wade Smith |
wade.smith1110@gmail.com |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wada Farms |
wade.smith1110@gmail.com |
self |
Grand Mound |
clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
18 |
2019-12-31 13:36 |
Anonymous (not verified) |
162.253.44.28 |
Wade Roth DBA Roth TV and Appliance |
Proprietorship |
1004 12th St, Belle Plaine, IA 52208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2019-12-09 |
Wade Roth |
WADEROTH@NETINS.NET |
Belle PLaine |
Benton |
Iowa |
Robert Sydnes |
Robert Sydnes |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wade Roth |
WADEROTH@NETINS.NET |
Self |
Belle Plaine |
Benton |
Iowa |
Robert Sydnes |
Kurt Feller |
Signed |
649 |
2021-09-21 13:15 |
Anonymous (not verified) |
208.126.118.26 |
Wade Smith DBA WADA Farms |
Proprietorship |
2428 270th st, Grand Mound, IA 52751 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-09-21 |
Wade Smith |
wade.smith1110@gmail.com |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wade Smith |
wade.smith1110@gmail.com |
self |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
272 |
2020-10-02 13:10 |
Anonymous (not verified) |
99.203.92.229 |
Batres Homes Renovation LLC |
Limited Liability Company |
3000 2nd Ave Des Moines Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-02 |
Gabriel Antonio Batres Huezo |
gabirlebatres7@gmail.com |
Des Moines |
Polk |
Iowa |
Blanca Silvia Leiva |
Luis Mariano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Walter Alexander Batres Huezo |
wbatres12@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Blanca Silvia Leiva |
Luis Mariano |
Signed |
136 |
2020-04-28 10:06 |
Anonymous (not verified) |
74.84.101.138 |
W. A. D. E., Inc. DBA Decorah Cleaners |
Proprietorship |
504 Heivly Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Owner |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
2035 |
2024-02-07 12:34 |
Anonymous (not verified) |
94.188.205.176 |
WAYNE GRAFFUNDER |
Proprietorship |
3244 358TH STREET, LAKE VIEW, IOWA 51450 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
WAYNE ALLEN GRAFFUNDER |
hdbearhunter@gmail.com |
LAKE VIEW |
SAC |
IOWA |
JOHN CLARENCE OLERICH |
ROBERT EUGENE BELT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
WAYNE ALLEN GRAFFUNDER |
hdbearhunter@gmail.com |
SELF |
LAKE VIEW |
SAC |
IOWA |
JOHN CLARENCE OLERICH |
ROBERT EUGENE BELT |
Signed |
1507 |
2023-03-09 08:16 |
Anonymous (not verified) |
94.188.207.230 |
Greufe Construction |
Proprietorship |
2820 230th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Wayne Greufe |
wgreufe@wmtel.net |
Blairsburg |
US |
United States |
Janet Greufe |
Janet Greufe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wayne Greufe |
wgreufe@wmtel.net |
Friend |
Blairsburg |
US |
United States |
Janet Greufe |
Janet Greufe |
Signed |
718 |
2021-11-05 13:41 |
Anonymous (not verified) |
209.252.172.87 |
Wayne Hunt |
Proprietorship |
405 E 4th St Tipton, Ia 52772 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-12 |
Wayne Hunt |
installation@bachmeiercarpetone.com |
Tipton |
Cedar |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wayne Hunt |
installation@bachmeiercarpetone.com |
Self |
Tipton |
Cedar |
Iowa |
Sarah Coberley |
Heather Howell |
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 |
1987 |
2024-01-16 12:35 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi urbandale LLc |
Limited Liability Company |
12509 Townsend Ava, Urbandale, IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Wen Zheng |
jenna18841002@hotmail.com |
Urbandale |
Dallas |
Iowa |
Jie Li |
Yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wen Zheng |
jenna18841002@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowas |
Jie Li |
Yingna zheng |
Signed |
908 |
2022-02-09 15:06 |
Anonymous (not verified) |
63.152.66.183 |
Shear Texture |
Limited Liability Company |
1427 A 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. |
2022-02-09 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
1480 |
2023-02-24 08:54 |
Anonymous (not verified) |
94.188.205.176 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-24 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
2087 |
2024-03-11 09:39 |
Anonymous (not verified) |
94.188.205.175 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-11 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
1934 |
2023-12-01 22:43 |
Anonymous (not verified) |
94.188.207.224 |
wasabi johnston llc |
Limited Liability Company |
7115 ridgedale ct, johnston, IA, 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
wenhui chen |
michaelchen@wasabidsm.com |
johnston |
polk |
Iowa |
wen Zheng |
Jenna Yu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
wenhui chen |
michaelchen@wasabidsm.com |
owner |
johnston |
polk |
IOWA |
wen zheng |
Jenna Yu |
Signed |
1991 |
2024-01-17 00:34 |
Anonymous (not verified) |
94.188.207.223 |
Wasabi urbandale llc |
Limited Liability Company |
7115 Ridgedale ct, Johnston,IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-17 |
Wenhui chen |
michaelchen@wasabidsm.com |
Johnston |
Polk |
Iowa |
Yilian lin |
Ji jie jie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wenhui chen |
michaelchen@wasabidsm.com |
Owner |
Johnston |
Polk |
Iowa |
Yilian lin |
Ji jie jie |
Signed |
2112 |
2024-03-22 08:22 |
Anonymous (not verified) |
94.188.205.174 |
WR TREE SERVICES |
Limited Liability Company |
1176 highway 9 Lansing iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-22 |
Wesley Adam Remund |
wesleyadamremund@gmail.com |
Lansing |
Allamakee |
Iowa |
JENNIFER K Harris |
Stefan M Remund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wesley Adam Remund |
wesleyadamremund@gmail.com |
OWNER |
Lansing |
Allamakee |
Iowa |
Jennifer K Harris |
Stefan M Remund |
Signed |
446 |
2021-03-23 12:39 |
Anonymous (not verified) |
174.198.72.209 |
Final Finish llc |
Limited Liability Company |
3824 12th st Des Moines Iowa 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-23 |
Wesley Robert Detman |
wesdet@gmail.com |
Drs Moines |
Polk |
Iowa |
Leah Laxton |
Lucas Laxton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wesley Robert Detman |
wesdet@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leah Laxton |
Lucas Laxton |
Signed |
1748 |
2023-07-17 06:35 |
Anonymous (not verified) |
94.188.205.177 |
Westys paint and stain llc |
Limited Liability Company |
1961 150th st waverly, ia 50677 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-17 |
Kaitlin westendorf |
westyspaint@gmail.com |
Waverly |
Bremer |
Iowa |
Kathy westendorf |
Michael westendorf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Westys paint & stain llc |
westyspaint@gmail.com |
Owner |
Waverly |
Bremer |
Iowa |
Kathy westendorf |
Michael westendorf |
Signed |
2064 |
2024-02-29 11:53 |
Anonymous (not verified) |
94.188.207.227 |
Quality Masonry LLC |
Limited Liability Company |
4121 14th st des moines ia 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
Wilian Nunez |
williamnunez77@gmail.com |
Des Moines |
IOWA |
United States |
Drake Rapaich |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wilian Nunez |
Williamnunez77@gmail.com |
Self |
Des Moines |
Polk |
IA |
Drake Rapaich |
Nathan Miller |
Signed |
2080 |
2024-03-07 12:57 |
Anonymous (not verified) |
94.188.205.168 |
Will's Bus Stuff LLC |
Limited Liability Company |
402 SE Grant St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-07 |
Will Boettcher |
wboettcher@centurionstoneofiowa.com |
Des Moines |
Iowa |
United States |
Tyler Franklin |
Troy Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Will Boettcher |
willsbusstuffllc@gmail.com |
Owner |
Ankeny |
Iowa |
United States |
Tyler Franklin |
Troy Klein |
Signed |
441 |
2021-03-18 16:20 |
Anonymous (not verified) |
173.25.156.33 |
CYALCO AVIATION LLC |
Limited Liability Company |
3710 W. MILWAUKEE ST, SPENCER, IA 51301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-03-18 |
WILLIAM A. VAN LENT |
bvl@veridian.net |
WEST DES MOINES |
POLK |
IOWA |
ERIN MONFORT NELSON |
COLE M. VAN LENT |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
WILLIAM A. VAN LENT |
bvl@veridian.net |
SAME |
WEST DES MOINES |
POLK |
IOWA |
ERIN MONFORT NELSON |
COLE M. VAN LENT |
Signed |
1920 |
2023-11-22 08:40 |
Anonymous (not verified) |
94.188.205.166 |
Demolition Services of Iowa, llc |
Limited Liability Company |
221 North Grant Ave., Elkhart, IA 50073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
ELKHART |
IA |
United States |
Ashley Whitehill |
Zach Whitehill |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
self |
Elkhart |
Polk |
IA |
Ashley Nicole Lee Whitehill |
Zachery Allen Whitehill |
Signed |
888 |
2022-02-03 14:40 |
Anonymous (not verified) |
174.215.230.111 |
Blakesley Enterprise |
Proprietorship |
609 Center 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. |
2022-02-03 |
William Blakesley |
Blakesleyb@msn.com |
Reinbeck |
Iowa |
Iowa |
Nichelle Blakesley |
Christine Willis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Blakesley |
Blakesleyb@msn.com |
Owner |
Reinbeck |
Iowa |
Iowa |
Nichelle Blakesley |
Christine Willis |
Signed |
1595 |
2023-04-24 12:34 |
Anonymous (not verified) |
94.188.205.166 |
Ankeny & Neighbors |
Proprietorship |
603 South St, Cambridge Iowa 50046 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-24 |
William Richard Borchard III |
william@damageddevicerepair.com |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Borchard III |
william@damageddevicerepair.com |
Sole proprietor/owner |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmore |
Signed |
1190 |
2022-07-07 12:00 |
Anonymous (not verified) |
172.243.111.71 |
Breuer Earthworks Inc. |
Proprietorship |
4512 148th Ave Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-07 |
William Breuer |
breuerearthworks@gmail.com |
Burlington |
Des Moines |
Iowa |
Donald Breuer |
Ericka Breuer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Breuer |
breuerearthworks@gmail.com |
Owner of Breuer Earthworks Inc. |
BURLINGTON |
Iowa |
United States |
Donald Breuer |
Ericka Breuer |
Signed |
225 |
2020-08-05 14:31 |
Anonymous (not verified) |
66.188.136.150 |
William Brickley |
Proprietorship |
327 E Prairie St., Wataga, IL 61488 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-03 |
William Brickley |
kschumacher@tricorinsurance.com |
Watage |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Brickley |
kschumacher@tricorinsurance.com |
Same |
Wataga |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
685 |
2021-10-20 14:14 |
Anonymous (not verified) |
65.144.174.26 |
william c sawhill |
Proprietorship |
1625 Delaware Ave, Des Moines, 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-20 |
William C Sawhill |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
Iowa |
Nicholas W Sawhill |
Jenny M Steben |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William C Sawhill |
workorders@shoproyalflooring.com |
Self |
Des Moines |
Polk |
Iowa |
Nicholas W Sawhill |
Jenny M Steben |
Signed |