588 |
2021-07-27 19:59 |
Anonymous (not verified) |
75.162.226.22 |
Andres Martinez |
Limited Liability Company |
3903 SW 3rd St. Des Moines, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-27 |
Andres Martinez |
and.am12am@gmail.com |
Des Moines |
Polk |
Iowa |
Carla Martinez |
Librado Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andres Martinez |
and.am12am@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Carla Martinez |
Librado Martinez |
Signed |
1355 |
2022-11-01 11:06 |
Anonymous (not verified) |
23.252.149.120 |
Randy J. Hackenmiller dba Hackenmiller Trucking |
Proprietorship |
606 Grain Millers Dr. PO Box 125, St. Ansgar, IA 50472-0125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-01 |
Randy J. Hackenmiller |
randhack@myomnitel.com |
St. Ansgar |
Mitchell |
Iowa |
Kent A. Wilder |
Rebecca L. Dobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy J. Hackenmiller |
randhack@myomnitel.com |
Self |
St. Ansgar |
Mitchell |
Iowa |
Kent A. Wilder |
Rebecca L. Dobson |
Signed |
2042 |
2024-02-12 13:07 |
Anonymous (not verified) |
94.188.205.175 |
Evelyn R Ventura Terrazas |
Proprietorship |
524 Terrence |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-12 |
Evelyn R Ventura Terrazas |
evelynterrazas@gmail.com |
Storm Lake |
Buena vista |
IA |
Juan García Oropeza |
Karen Rodríguez Pantoja |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evelyn R Ventura Terrazas |
evelynterrazas@gmail.com |
Proprietorship |
Storm Lake |
Buena vista |
IA |
Juan Garcia Oropeza |
Karen Rodríguez Pantoja |
Signed |
700 |
2021-10-29 11:04 |
Anonymous (not verified) |
174.198.66.50 |
T&C Lawn Care LLC |
Limited Liability Partnership |
1827 Black Hawk St Waterloo IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-29 |
Cody R Woodley |
cody.woodley50@gmail.com |
Cedar Falls |
Blackhawk |
Iowa |
Tara R Woodley |
Sara Woodley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristi S. Demuth Agency, Inc. |
kdemuth@amfam.com |
Client |
Waverly |
Bremer |
Iowa |
Cody R Woodley |
Tyler M Croft |
Signed |
1467 |
2023-02-17 16:14 |
Anonymous (not verified) |
94.188.205.169 |
H & C Construction |
Limited Liability Company |
708 Vine Street Lucas IA 50151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Colton Charles Clarke |
ccclarke95@gmail.com |
Truro |
IA |
United States |
Hailey Sullivan |
Shelby Comer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
H & C Construction |
ccclarke95@gmail.com |
Manager |
Truro |
IA |
United States |
Hailey Sullivan |
Shelby Comer |
Signed |
2154 |
2024-04-16 08:05 |
Anonymous (not verified) |
94.188.207.226 |
Lanz Pork Inc |
Proprietorship |
12905 N 1050th Road, Macomb, IL 61455 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-02 |
Andrew M Riggins |
kellylanz1967@gmail.com |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew M Riggins |
kellylanz1967@gmail.com |
Self |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
812 |
2021-12-22 17:31 |
Anonymous (not verified) |
166.181.85.89 |
Demmer Construction |
Proprietorship |
203 Michigan Ave Farley, IA 52046 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-22 |
Charles Demmer |
charliedemmer@gmail.com |
Farley |
Dubuque |
Ia |
Michele Demmer |
Jennifer White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Demmer |
charliedemmer@gmail.com |
Self |
Farley |
Dubuque |
Ia |
Michele Kay Demmer |
Jennifer Marie White |
Signed |
1579 |
2023-04-17 17:00 |
Anonymous (not verified) |
94.188.205.177 |
Home provisions siding LLC |
Limited Liability Company |
1816 Francis avenue apt 1 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Luis Alberto Ramirez Mendez |
luisramirez4308@icloud.com |
Desmoines |
Polk |
Iowa |
Alexandra Gomez-Benitez |
Marcedez ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Alberto Ramirez Mendez |
luisramirez4308@icloud.com |
None |
Des Moines |
Polk |
Iowa |
Alexandra Gomez-Benitez |
Marcedez Roxana Ramirez |
Signed |
1691 |
2023-06-14 19:20 |
Anonymous (not verified) |
94.188.205.174 |
Amazing Painting LLC |
Limited Liability Company |
1301 Boyd Street, Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-14 |
Evan Michael Regenwether |
Evan@amazingpaintingia.com |
Des Moines |
Polk |
Iowa |
Austin Matthew Regenwether |
Abby Marie Regenwether |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evan Michael Regenwether |
evan@amaingpaintingia.com |
Owner |
Des Moines |
Polk |
Iowa |
Austin Matthew Regenwether |
Abby Regenwether |
Signed |
44 |
2020-01-28 12:55 |
Anonymous (not verified) |
173.24.181.211 |
AMANDA FIEDLER |
Proprietorship |
10 5TH AVE NW FOSTORIA, IA 51340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-28 |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
FOSTORIA |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
FOSTORIA |
CLAY |
IA |
JOSPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
156 |
2020-05-13 20:37 |
Anonymous (not verified) |
216.106.236.82 |
MR Electric LLC |
Limited Liability Company |
1853 230st Inwood, IA 51240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-13 |
Matthew Rozeboom |
matt.rozeboom@gmail.com |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Rozeboom |
matt.rozeboom@gmail.com |
Owner/President |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
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 |
268 |
2020-09-22 09:21 |
Anonymous (not verified) |
174.217.16.178 |
Ayala Brothers Painting & Drywall |
Proprietorship |
25089 H Ave Adel IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-22 |
Edson Ayala Arizaga |
Ayalabrospainting@gmail.com |
Adel |
Dallas |
Iowa |
Abel Ayala |
Laura Orozco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edson Ayala Arizaga |
Edsonayala.12@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Abel Ayala |
Laura Orozco |
Signed |
1035 |
2022-04-05 12:03 |
Anonymous (not verified) |
199.120.121.97 |
Bruce Peters Painting |
Proprietorship |
53568 Rosewood Road, Walnut IA 51577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Bruce Peters |
bpeters1992@yahoo.com |
Walnut |
Pottawattamie |
Iowa |
Marie Peters |
Angie Gettys |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Peters |
bpeters1992@yahoo.com |
self |
Walnut |
Pottawattamie |
Iowa |
Marie Peters |
Angie Gettys |
Signed |
380 |
2021-02-01 15:04 |
Anonymous (not verified) |
192.30.185.142 |
Chelos Framing Crew |
Proprietorship |
501 Colon Street, Sioux City, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-01 |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
Signed |
1147 |
2022-06-08 11:29 |
Anonymous (not verified) |
67.55.184.250 |
Morgan Anderson |
Proprietorship |
23379 120th Ave, Mediapolis, IA 52637 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-08 |
Morgan Duane Anderson |
morgananderson6.ma@gmail.com |
Mediapolis |
IA |
United States |
Kelly S Lanz |
Monte A Lanz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Morgan D. Anderson |
morgananderson6.ma@gmail.com |
sole proprietor |
Mediapolis |
Louisa |
Iowa |
Kelly Lanz |
Monte Lanz |
Signed |
1834 |
2023-09-08 15:04 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Tucker |
Proprietorship |
19000 hwy 69 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-08 |
Ryan Tucker |
rtlltucker@yahoo.com |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Tucker |
rtlltucker@yahoo.com |
Officer |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
492 |
2021-04-22 08:33 |
Anonymous (not verified) |
66.188.136.150 |
Adrian Hackney |
Proprietorship |
1513 7th St. Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-20 |
Adrian Hackney |
kschumacher@tricorinsurance.com |
Boone |
Boone |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Hackney |
kschumacher@tricorinsurance.com |
Same |
Boone |
Boone |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
1259 |
2022-08-15 13:47 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd St., Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-15 |
Johnathan Scott |
karma27895@gmail.com |
East Moline |
Rock Island |
Illinois |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1946 |
2023-12-06 16:51 |
Anonymous (not verified) |
94.188.205.168 |
Blue Sky Renovations Iowa LLC |
Limited Liability Company |
2059 Lyon St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sell Now Iowa |
team@sellnowiowa.com |
None |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
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 |
1371 |
2022-11-14 10:55 |
Anonymous (not verified) |
166.181.86.95 |
Dean Abramczak |
Proprietorship |
524 Nodaway Dr center Point Iowa 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-16 |
Dean Abramczak |
gabramczak@gmail.com |
Center Point |
IA |
United States |
Brenda Oconner |
Kenny McGraw |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dean Abramczak |
gabramczak@gmail.com |
I am the only employee I own the company |
Center Point |
IA |
United States |
Brenda Oconnner |
Kenny McGraw |
Signed |
2058 |
2024-02-26 16:32 |
Anonymous (not verified) |
94.188.207.224 |
performance gutter |
Proprietorship |
PO BOX 306, NORWALK IOWA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-26 |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
OWNER |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
716 |
2021-11-05 13:22 |
Anonymous (not verified) |
209.252.172.87 |
Rick Clifford Clifford Custom Tile & Flooring |
Proprietorship |
1563 Palmer Ct NE, Solon, IA 52333 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-24 |
Rick Clifford |
cliffordcustomtile@gmail.com |
Solon |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Clifford Clifford Custom Tile & Flooring |
cliffordcustomtile@gmail.com |
Self Employed |
Solon |
Johnson |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1483 |
2023-02-25 14:57 |
Anonymous (not verified) |
94.188.205.168 |
Van Wyk Lawn Services |
Limited Liability Company |
14486 S. 128th ave E. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-24 |
Anthony Eugene Van Wyk |
vanwykturf@gmail.com |
Lynnville |
Iowa |
United States |
Ashley Lynn Van Wyk |
Abby Christine Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Eugene Van Wyk |
vanwykturf@gmail.com |
Self/Owner |
Lynnville |
Iowa |
United States |
Ashley Lynn Van Wyk |
Abby Christine Peterson |
Signed |
2170 |
2024-04-22 10:11 |
Anonymous (not verified) |
94.188.207.224 |
Joy Ride Transport |
Limited Liability Company |
3105 SE Miehe Drive, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ted Cochran |
ted@ridejoyride.com |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Cochran |
ted@ridejoyride.com |
Self |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
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 |
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 |
1707 |
2023-06-25 10:39 |
Anonymous (not verified) |
94.188.207.224 |
Michael D Ray |
Proprietorship |
4944 Holcomb Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Michael D Ray Jr |
mdray01@msn.com |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Ray |
mdray01@msn.com |
Owner Proprietor |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
281 |
2020-10-20 08:58 |
Anonymous (not verified) |
136.37.174.39 |
Merge Midwest Engineering, LLC |
Limited Liability Company |
2668 W Catalpa Street, Olathe, KS 66061 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Michael Lee Baer |
lbaer@mergemidwest.com |
Louisburg |
Miami |
Kansas |
Heather Lee Baer |
Ami Bowes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Marie Clayton |
jclayton@mergemidwest.com |
Self |
Olathe |
Johnson |
Kansas |
Patrick McCartney |
David Jahner |
Signed |
1048 |
2022-04-14 14:17 |
Anonymous (not verified) |
208.38.229.255 |
Mean Green Lawn Care |
Limited Liability Company |
2628 W 59th st Davenport Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Anthony mccash |
meangreenlawncare20@gmail.com |
Davenport |
Scott |
Iowa |
Clarissa Oliva |
Julie Thornman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony McCash |
meangreenlawncare20@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Clarissa Oliva |
Julie Thornman |
Signed |
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 |
1160 |
2022-06-20 10:08 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th ave masonville IA, 50654 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-20 |
chris cooper |
Chris_cooper@highcaliberfiber.com |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
Blake Dean Elbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
self |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
BLake Dean Elbert |
Signed |
1847 |
2023-09-18 18:20 |
Anonymous (not verified) |
94.188.205.168 |
William O'Brien |
Proprietorship |
1069 Yukon Ave Sumner Iowa 50674 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-18 |
William Charles O'Brien |
wcobrien63@gmail.com |
Sumner |
Bremer |
Iowa |
Patrick B Dillon |
Christina Rader |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Charles O'Brien |
wcobrien63@gmail.com |
self |
Sumner |
Bremer |
Iowa |
Patrick B Dillon |
Christina Rader |
Signed |
505 |
2021-05-10 07:06 |
Anonymous (not verified) |
69.63.16.2 |
Three Boys Contracting LLC |
Limited Liability Company |
1108 Cullen Dr, Tiffin, IA 52340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-08 |
Brandon J Campbell |
threeboyscarpentry@gmail.com |
Tiffin |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon J Campbell |
threeboyscarpentry@gmail.com |
Managing Member |
Tiffin |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
1272 |
2022-08-19 09:36 |
Anonymous (not verified) |
75.162.65.221 |
William Jones |
Limited Liability Company |
1639 E 13th St Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-19 |
William Jones |
billjones1229@yahoo.com |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Jones |
billjones1229@yahoo.com |
Self |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1959 |
2023-12-15 13:32 |
Anonymous (not verified) |
94.188.205.169 |
DeFreeceBuilt LLC |
Limited Liability Company |
216 Rellim Dr Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-15 |
Dylan DeFreece |
dylan@defreecebuiltia.com |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dylan DeFreece |
dylan@defreecebuiltia.com |
N/A |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
617 |
2021-08-23 13:58 |
Anonymous (not verified) |
172.58.84.152 |
Jose barrientos |
Proprietorship |
1844 n tony 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-08-23 |
Jose Barrientos |
70barrientos70@gmail.com |
Wichita |
Sedwick |
Kansas |
Roberto valle |
Juan lopez |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jose barrientos |
70barrientos70@gmail.com |
Employer |
Wichita |
Sedwick |
Kansas |
Vladimir faustino |
Rene Grande |
Signed |
1384 |
2022-12-08 13:11 |
Anonymous (not verified) |
172.58.81.43 |
Sehic G&S, LLC. |
Limited Liability Company |
4201 62nd st apt 4 Urbandale Ia 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-09 |
Bajro sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
2071 |
2024-03-01 11:08 |
Anonymous (not verified) |
94.188.207.229 |
Level92 Screen Printing LLC |
Limited Liability Company |
2500 W 2nd Ave Ste 10, Indianola, IA 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
Alison Vice |
orders@level92.com |
Indianola |
Warren |
IA |
Jake Vice |
Grant Darrah |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alison Vice |
orders@level92.com |
Partner |
Indianola |
Warren |
IA |
Jake Vice |
Grant Darrah |
Signed |
729 |
2021-11-05 15:25 |
Anonymous (not verified) |
209.252.172.87 |
Joshua Yoder S&S Window Treatments |
Proprietorship |
2555 Hwy 1 SW, 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. |
2020-08-20 |
Joshua Yoder |
installation@bachmeiercarpetone.com |
Iowa City |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Yoder |
installation@bachmeiercarpetone.com |
Owner |
Iowa City |
Johnson |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1496 |
2023-03-06 11:24 |
Anonymous (not verified) |
94.188.207.227 |
Carrillo Drywall, LLC |
Limited Liability Company |
119 Marsh St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-06 |
Yesenia Carrillo |
yesecarrillo84@gmail.com |
Waterloo |
IA |
United States |
Rene Carrillo Jr |
Martha Basurto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Hildman |
kyleh@sinnottagency.com |
Insurance Agent |
Waterloo |
IA |
United States |
Rene Carrillo Jr |
Martha Basurto |
Signed |
2183 |
2024-04-26 14:49 |
Anonymous (not verified) |
94.188.205.168 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-01 |
Jared Birkenholz |
jareddrewb@gmail.com |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
841 |
2022-01-14 15:23 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Hanover |
Jo Daviess |
IL |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
1608 |
2023-04-26 11:51 |
Anonymous (not verified) |
94.188.205.167 |
Jesus Lozano |
Proprietorship |
1334 E 16th st Des Moines Iowa 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
Jesus Lozano |
Jesuslozano0086@icloud.com |
Des Moines |
Polk |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesus Lozano |
Jesuslozano0086@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
1720 |
2023-07-05 07:19 |
Anonymous (not verified) |
94.188.207.224 |
Doug FGerneding |
Proprietorship |
21618 270th St Carroll IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-05 |
Doug Ferneding |
dougferneding@gmail.com |
Carroll |
Iowa |
Iowa |
Jaynie Ferneding |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Ferneding |
dougferneding@gmail.com |
same |
Carroll |
Iowa |
Iowa |
Jaynie Ferneding |
Brenda Klein |
Signed |
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 |
185 |
2020-06-12 14:50 |
Anonymous (not verified) |
173.28.28.57 |
Aaron & Eliesa Thomas |
Partnership |
706 3rd Avenue, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-20 |
Aaron & Eliesa Thomas |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron & Eliesa Thomas |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
952 |
2022-03-05 18:23 |
Anonymous (not verified) |
108.59.100.21 |
Heaven Sent PC LLC |
Limited Liability Company |
604 Allamakee St, Waukon,IA 52172 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-01 |
Justin Piggott |
heavensentpetcremation@gmail.com |
Waukon |
Allamakee |
Iowa |
Kaia Piggott |
Jane M Regan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Piggott |
heavensentpetcremation@gmail.com |
Member of LLC |
Waukon |
Allamakee |
Iowa |
Kaia Piggott |
Jane M Regan |
Signed |
297 |
2020-10-30 10:43 |
Anonymous (not verified) |
216.51.132.207 |
Kregel Farm Partnership |
Limited Liability Partnership |
30392 Garber RD Guttenberg, IA 52052 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-08 |
Travis Kregel |
TRAVIS.KREGEL@GMAIL.COM |
Garber |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Kregel |
TRAVIS.KREGEL@GMAIL.COM |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |