1689 |
2023-06-13 19:55 |
Anonymous (not verified) |
94.188.207.227 |
Gerardo Reyes-Lopez |
Limited Liability Company |
908 West 1st Street, Waterloo, IA ,50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-13 |
Gerardo Reyes-lopez |
greyeslopez9@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Guillermina Lopez |
Bernardo Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Denise Seitsinger |
denise@harmsinsuranceagency.com |
Insurance Agent |
Sumner |
Bremer |
Iowa |
Gerardo Reyes |
Bernardo Reyes |
Signed |
1690 |
2023-06-13 20:01 |
Anonymous (not verified) |
94.188.207.227 |
Gerardo Reyes-Lopez |
Limited Liability Company |
908 West 1st Street, Waterloo, Iowa, 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-13 |
Gerardo Reyes-lopez |
bernardo@reyesconstruct.com |
Waterloo |
IA |
United States |
Guillermina Lopez |
Bernardo Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Denise Seitsinger |
denise@harmsinsuranceagency.com |
Insurance Agent |
Sumner |
Bremer |
Iowa |
Gerardo Reyes |
Bernardo Reyes |
Signed |
2220 |
2024-05-10 11:10 |
Anonymous (not verified) |
94.188.207.229 |
Froyo To Go, LLC |
Limited Liability Company |
909 4th Ave S., Denison, Iowa 51442 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-10 |
Lucas Gillmor |
lgillmor@dmuonline.com |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevis Beeck |
trevis.beeck.u0ms@statefarm.com |
State Farm Agent |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
2219 |
2024-05-10 10:20 |
Anonymous (not verified) |
94.188.207.228 |
Froyo To Go, LLC |
Limited Liability Company |
909 4th Ave. South, Denison, 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. |
2024-05-10 |
Derek Lambert |
drdereklambert@gmail.com |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevis Beeck |
trevis.beeck.u0ms@statefarm.com |
I am the State Farm Agent who is submitting the Business Policy |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
68 |
2020-02-19 12:00 |
Anonymous (not verified) |
198.14.241.59 |
SIERRA ROOFING LLC |
Limited Liability Company |
909 N ELM ST WEST LIBERTY IA 52776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
ABRAHAM GRANJENO |
SIERRA89@GMAIL.COM |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ABRAHAM GANJENO |
SIERRA89@GMAIL.COM |
OWNER |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
1580 |
2023-04-17 20:22 |
Anonymous (not verified) |
94.188.205.167 |
Lance Van Der weerd |
Limited Liability Company |
909 S Adams Street Rock Rapids IA 51246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Rock Rapids |
IA |
United States |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Myself |
Rock Rapids |
Lyon |
Iowa |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
2228 |
2024-05-16 11:10 |
Anonymous (not verified) |
94.188.207.224 |
Gosselink Builders |
Limited Liability Company |
910 197th Place, Pella, IA 50219 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Dean Dingeman |
deanding2014@gmail.com |
Pella |
Marion |
Iowa |
Brad Terpstra |
Robert Hallman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dean Dingeman |
deanding2014@gmail.com |
Self |
Pella |
Marion |
Iowa |
Brad Terpstra |
Robert Hallman |
Signed |
170 |
2020-06-01 13:31 |
Anonymous (not verified) |
173.28.28.57 |
Rachel Poppens |
Proprietorship |
910 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Rachel Poppens |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rachel Poppens |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
223 |
2020-08-05 13:22 |
Anonymous (not verified) |
173.28.28.57 |
Shear Beautique Retail, LLC |
Limited Liability Company |
910 Parriott, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-28 |
Lindsey Poppens |
cmins_re@mchsi.com |
Allison |
BUTLER |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lindsey Poppens |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
224 |
2020-08-05 13:25 |
Anonymous (not verified) |
173.28.28.57 |
Shear Beautique Retail, LLC |
Limited Liability Company |
910 Parriott, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-28 |
Rachel Poppens |
cmins_re@mchsi.com |
Allison |
Butler |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rachel Poppens |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
1890 |
2023-11-01 19:22 |
Anonymous (not verified) |
94.188.207.228 |
JACK SCHADE |
Proprietorship |
911 Broad St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-01 |
jack allan schade |
jackschade@yahoo.com |
Plymouth |
IA |
IA |
jack allan schade |
jack allan schade |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jack allan schade |
jackschade@yahoo.com |
self |
Plymouth |
IA |
IA |
jack allan schade |
jack allan schade |
Signed |
35 |
2020-01-13 13:23 |
Anonymous (not verified) |
173.28.28.57 |
Milkhouse Market, LLC |
Limited Liability Company |
911 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-30 |
MARY MEYER |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MARY MEYER |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
598 |
2021-08-06 19:04 |
Anonymous (not verified) |
107.77.208.84 |
Paul Adams |
Proprietorship |
914 Bayfield drive Denton TX 76209 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-06 |
Paul T Adams |
ptadams61@yahoo.com |
Denton |
Denton |
Tx |
Jeanie Moses |
Richard Moses |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul T Adams |
ptadams61@yahoo.com |
Friends |
Milan |
Rock Island |
Illinois |
Jeanie Moses |
Richard Moses |
Signed |
1711 |
2023-06-26 16:50 |
Anonymous (not verified) |
94.188.207.224 |
Innovative Behavioral Therapy, LLC |
Limited Liability Company |
915 Main St. 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. |
2023-06-26 |
Ashley Andrew |
ashley@innovativebehavioraltherapy.com |
Adel |
Dallas |
Iowa |
Thomas Atherton |
Brenda Barto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ashley Andrew |
ashley@innovativebehavioraltherapy.com |
Self |
Adel |
Dallas |
Iowa |
Thomas Atherton |
Brenda Barto |
Signed |
1428 |
2023-01-23 19:31 |
Anonymous (not verified) |
206.72.6.241 |
Brian Grote |
Limited Liability Company |
919 Highway 37 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-23 |
Brian Grote |
grote919@gmail.com |
Earling |
Iowa |
United States |
Jaurel Grote |
Dan Grote |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leinen Construction |
grote919@gmail.com |
sub |
Harlan Iowa |
Iowa |
United States |
Jaurel Grote |
Dan Grote |
Signed |
786 |
2021-12-09 15:37 |
Anonymous (not verified) |
216.51.251.31 |
3F Express, LLC |
Limited Liability Company |
920 32nd Ave West Po Box 1117 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. |
(1) I am not electing the employers’ liability coverage. |
2021-12-09 |
Tess Jackson |
accounting@3fexpressllc.com |
Milford |
Dickinson |
Iowa |
Amanda Wolff |
Mandy Kabrick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tess Jackson |
accounting@3fexpressllc.com |
Owner |
Milford |
Dickinson |
IA |
Amanda Wolff |
Mandy Kabrick |
Signed |
1752 |
2023-07-17 13:21 |
Anonymous (not verified) |
94.188.207.225 |
GPS Construction |
Limited Liability Company |
920 Wolf Creek Polk City, IA 50226 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2023-07-17 |
Gregory Schultz |
gregpschultz@gmail.com |
POLK CITY |
IA |
United States |
Dillon Temple |
Derek Temple |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gregory Schultz |
gregpschultz@gmail.com |
Owner |
POLK CITY |
IA |
United States |
Dillon Temple |
Derek Temple |
Signed |
1490 |
2023-03-03 10:31 |
Anonymous (not verified) |
94.188.205.175 |
Bagby Lawncar and More |
Limited Liability Company |
921 Pleasant Street, Des Moines IA 50309 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-03 |
Cory Michael Bagby |
bagbylawncareandmore@gmail.com |
921 Pleasant Street |
Polk |
Iowa |
Kelly Coluzzi |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Bagby |
babylawncareandmore@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Kelly Coluzzi |
Erick Schuldt |
Signed |
663 |
2021-10-04 09:45 |
Anonymous (not verified) |
166.181.80.1 |
Matthew Winters |
Proprietorship |
9220 Summit Dr Johnston IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-04 |
Matthew Winters |
mattwinters55@gmail.com |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Winters |
mattwinters55@gmail.com |
Self |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
883 |
2022-02-02 14:07 |
Anonymous (not verified) |
104.201.67.178 |
Juan Monterde |
Proprietorship |
9235 Swanson Blvd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Juan Monterded |
s.thomas@nationwideofficecare.com |
Cedar Rapids |
Linn |
Iowa |
Cory Shelton |
Scott D Thomas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott D Thomas |
scottthomascpa@msn.com |
Consultant |
West Des Moines |
IA |
United States |
Rich Darr |
Mari Lopez |
Signed |
1855 |
2023-09-27 12:56 |
Anonymous (not verified) |
94.188.207.224 |
Lincoln Hotel Group |
Limited Liability Company |
9240 Andermatt Drive Suite 1 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-27 |
John Edward Klimpel |
jklimpel@lincolnhotelgroup.com |
Lincoln |
Lancaster |
NE |
Carrie A. Fleck |
Jill N. Korta |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brent Besch |
brent.besch@marshmma.com |
Client |
Lincoln |
Nebraska |
NE |
Carrie A Fleck |
Jill N Korta |
Signed |
1064 |
2022-04-21 12:48 |
Anonymous (not verified) |
174.199.77.87 |
Hocken Construction LLC |
Limited Liability Company |
926 State St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Ryan Hocken |
ryan.hocken@yahoo.com |
Osage |
Mitchell |
Iowa |
Melissa Hocken |
Tyler Schwarck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Hocken |
ryan.hocken@yahoo.com |
Owner |
Osage |
Mitchell |
Iowa |
Melissa Hocken |
Tyler Schwarck |
Signed |
353 |
2021-01-11 14:38 |
Anonymous (not verified) |
66.188.136.150 |
Igor Curguz |
Proprietorship |
927 1/2 W Grand Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-11 |
Igor Curguz |
kschumacher@tricorinsurance.com |
Beloit |
Rock |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Igor Curguz |
kschumacher@tricorinsurance.com |
Same |
Beloit |
Rock |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
1280 |
2022-08-22 15:48 |
Anonymous (not verified) |
104.222.83.187 |
Cabinet Kulture LLC |
Limited Liability Company |
927 N. West St. Carroll, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Jordan Ellis |
cabinetkulture@gmail.com |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cabinet Kulture LLC |
cabinetkulture@gmail.com |
Same person |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
234 |
2020-08-18 09:13 |
Anonymous (not verified) |
67.55.224.208 |
Anthony Keahi dba Hawaiian Handyman |
Proprietorship |
928 8th Ave SE, Sioux Center, IA 51250-2502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-17 |
Anthony Keahi |
hhkeahi@gmail.com |
Sioux Center |
Sioux |
Iowa |
Kyle Blankers |
Julia Huisman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Keahi |
hhkeahi@gmail.com |
Self - sole proprietorship |
Sioux Center |
Sioux |
Iowa |
Kyle Blankers |
Julia Huisman |
Signed |
1567 |
2023-04-12 10:01 |
Anonymous (not verified) |
94.188.205.177 |
Hearts on fire llc |
Limited Liability Partnership |
931 14th Ave Se Altoona Iowa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-12 |
Matt Moffet |
dsm@fibrenew.com |
Altoona |
Polk |
Iowa |
Jason McDowell |
Mike Wennekamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Moffet |
dam@fibrenew.com |
Owner |
Altoona |
Polk |
Iowa |
Jason McDowell |
Mike Wennekamp |
Signed |
1329 |
2022-10-10 10:55 |
Anonymous (not verified) |
173.25.222.69 |
Eli's |
Limited Liability Company |
931 S Van Buren St Iowa City, Iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-10 |
Elijah Ortiz |
eortiz15@gmail.com |
Iowa City |
Johnson |
Iowa |
Erica Mason |
Bryan Horrell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elijah Ortiz |
eortiz15@gmail.com |
Proprietor |
Iowa City |
Johnson |
Iowa |
Erica Mason |
Bryan Horrell |
Signed |
2038 |
2024-02-08 07:44 |
Anonymous (not verified) |
94.188.205.167 |
Travis Toney |
Limited Liability Company |
932 w12th street south newton ia 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Travis Duane Toney |
travistoney1984@gmail.com |
Newton |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Phil glazer |
kg_Info@capitallandscaping.com |
Contractor |
Des Moines |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
1953 |
2023-12-12 15:38 |
Anonymous (not verified) |
94.188.207.226 |
Ryan Gideon |
Proprietorship |
9320 Elmcrest 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. |
2023-12-12 |
Ryan Gideon |
rgid8403@gmail.com |
Norwalk |
Warren |
IA |
Jim Lane |
Jim Lane |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Gideon |
rgid8403@gmail.com |
Owner |
Norwalk |
Warren |
IA |
jim Lane |
Jim Lane |
Signed |
258 |
2020-09-15 13:14 |
Anonymous (not verified) |
50.83.182.140 |
Moyer Painting |
Proprietorship |
934 Norwood Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-15 |
jerome Moyer |
moyer_painting@live.com |
Norwalk |
IA |
United States |
Sally Moyer |
Adam Adams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jerome b moyer |
moyer_painting@live.com |
Self |
norwalk |
IA |
United States |
sally moyer |
Adam Adams |
Signed |
110 |
2020-04-06 14:13 |
Anonymous (not verified) |
99.203.98.177 |
Stifel seasonal services |
Limited Liability Company |
935 4th street waukee |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-06 |
Dalton Stifel |
daltonstifel@icloud.com |
waukee |
Dallas |
IA |
Bryant ternes |
Tammy stifel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Stifel |
daltonstifel@icloud.com |
Owner |
waukee |
Dallas |
IA |
Bryant Ternes |
Tammy Stifel |
Signed |
1884 |
2023-10-27 18:32 |
Anonymous (not verified) |
94.188.205.177 |
J&M dry wall |
Proprietorship |
948 Kern St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-27 |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Waterloo |
Black hawk |
IA |
Luis flores |
Luis flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Self |
Waterloo |
Black hawk |
IA |
Luis Flores |
Luis flores |
Signed |
2248 |
2024-05-30 12:36 |
Anonymous (not verified) |
94.188.205.177 |
Grigsby Construction |
Proprietorship |
948 Walter St Lisbon, Ia 52253 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-30 |
Perry Grigsby |
grigsbyconstruction@hotmail.com |
Lisbon |
Linn |
Iowa |
Jim Olsem |
Steve Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perry Grigsby |
grigsbyconstruction@hotmail.com |
Self-sole proprietor |
Lisbon |
Linn |
Iowa |
Jim Olsem |
Steve Williams |
Signed |
1493 |
2023-03-05 22:42 |
Anonymous (not verified) |
94.188.207.226 |
Wyckoff Heating and Cooling |
Proprietorship |
95 hwy 5 carlisle, ia 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-05 |
Travis Keeney |
knytrav@aol.com |
carlisle |
warren |
iowa |
James Ren |
Troy Keeney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Keeney |
knytrav@aol.com |
Subcontractor |
carlisle |
warren |
iowa |
James Ren |
Troy Keeney |
Signed |
1451 |
2023-02-13 13:27 |
Anonymous (not verified) |
94.188.205.168 |
Better Built Floors, LLC |
Limited Liability Company |
950 Spruce street Waukee, IA, 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-13 |
Bodhi Cox |
betterbuiltfloors@gmail.com |
waukee |
dallas |
iowa |
Bodhi Cox |
Daniel Cox |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bodhi Cox |
betterbuiltfloors@gmail.com |
i am thge owner/operator |
waukee |
dallas |
iowa |
Bodhi Cox |
Daniel Cox |
Signed |
1399 |
2022-12-22 08:40 |
Anonymous (not verified) |
45.16.156.93 |
Valley Five, LLC DBA L & N Docks and Lifts |
Limited Liability Company |
9523 W 151st Ter Overland Park, KS 66221 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-22 |
Steven Dolezal |
steven.w.dolezal@gmail.com |
Overland Park |
Johnson |
Kansas |
Joan Dolezal |
Kelsey Dolezal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Dolezal |
steven.w.dolezal@gmail.com |
Owner |
Overland Park |
Johnson |
Kansas |
Joan Dolezal |
Kelsey Dolezal |
Signed |
1573 |
2023-04-14 13:43 |
Anonymous (not verified) |
94.188.205.167 |
Jaxon Kressley |
Proprietorship |
954 Boston Way, #12, Corralville, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-14 |
Jaxon Kressley |
jaxon@optionsexteriors.com |
Corralville |
Johnson |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaxon Kressley |
jaxon@optionsexteriors.com |
Owner/Self |
Corralville |
Johnson |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
1229 |
2022-07-26 15:56 |
Anonymous (not verified) |
173.31.102.238 |
Rai Neu Jo LLC |
Limited Liability Company |
957 Westwood Dr NW Cedar Rapids, Iowa 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-26 |
Craig Edward Johnson |
cejohnson119@yahoo.com |
Cedar Rapids |
Linn |
Iowa |
Becky Lynn Johnson |
Patricia Ann Coghlan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Edward Johnson |
cejohnson119@yahoo.com |
Same person |
Cedar Rapids |
Linn |
Iowa |
Becky Lynn Johnson |
Patricia Ann Coghlan |
Signed |
2207 |
2024-05-07 09:44 |
Anonymous (not verified) |
94.188.207.226 |
Rodrimart brothers corp |
Limited Liability Company |
958 8th ave nw Altoona 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Enrique Rodriguez |
carluto_1983@hotmail.com |
Altoona |
Polk |
Iowa |
Adan boge |
Lonce wester |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enrique Rodriguez |
carluto_1983@hotmail.com |
President |
Altoona |
Polk |
Iowa |
Adan boge |
Leans wester |
Signed |
1898 |
2023-11-09 09:56 |
Anonymous (not verified) |
94.188.207.227 |
RC Restoration LLC |
Limited Liability Company |
991 June Drive, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-09 |
Luke Hoffmann |
luke@rentcube.com |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Hoffman |
luke@rentcube.com |
Owner |
Dubuque |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
1218 |
2022-07-21 10:55 |
Anonymous (not verified) |
173.27.17.3 |
LeafFilter North LLC |
Proprietorship |
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. |
2022-07-21 |
Craig Stang |
stangcraig@gmail.com |
Silvis |
Rock island |
IL |
Cody Dunbar |
Tiffani Branham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LeafFilter North LLC |
cdunbar@leaffilter.com |
Install manager |
Bettendorf |
Iowa |
United States |
Cody dunbar |
Tiffani Branham |
Signed |
1362 |
2022-11-08 08:36 |
Anonymous (not verified) |
157.52.56.205 |
Martin Clip & Trim LLC |
Proprietorship |
Box 383 Urbana Iowa 52345 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-08 |
Armin Martin |
arminbonnie@aol.com |
Urbana |
Benton |
Iowa |
Melissa Stieferman |
Christin Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Armin Martin |
arminbonnie@aol.com |
Self |
Urbana |
Benton |
Iowa |
Melissa Stieferman |
Christin Martin |
Signed |
1308 |
2022-09-14 21:25 |
Anonymous (not verified) |
166.196.110.63 |
Anhalt Trucking |
Limited Liability Company |
Canby MN |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-13 |
Jordan J Anhalt |
anhalt.trucking@gmail.com |
Canby |
MN |
United States |
Ashley Anhalt |
Jace Anhalt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan J Anhalt |
anhalt.trucking@gmail.com |
Same |
Canby |
MN |
United States |
Ashley Anhalt |
Jace Anhalt |
Signed |
720 |
2021-11-05 13:57 |
Anonymous (not verified) |
209.252.172.87 |
Rick Klemesrud Brookstin Flooring |
Proprietorship |
Coralville, Ia 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-23 |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Coralville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Self |
Croalville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
1401 |
2022-12-23 09:07 |
Anonymous (not verified) |
75.162.43.221 |
Capital Express |
Limited Liability Company |
Council is Chris Blunk out of omaha NB. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-09-09 |
Nicholas Michelfelder |
nicmichelfelder@gmail.com |
8018 Valdez Circle |
polk |
iowa |
Ted Michelfelder |
lucy Sanderson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Chris Blunk |
cblunk@harrislawomaha.com |
None |
1400 SE gateway Dr. 105 |
Polk |
IA |
Theodore Michelfelder |
Rick Isacson |
Signed |
1921 |
2023-11-22 12:14 |
Anonymous (not verified) |
94.188.205.177 |
Julie Drtina |
Proprietorship |
Cresco Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
Julie Drtina |
juliedrtina@hotmail.com |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julie Drtina |
juliedrtina@hotmail.com |
self |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1893 |
2023-11-02 14:39 |
Anonymous (not verified) |
94.188.205.177 |
Dagoberto Nuñez |
Proprietorship |
Iowa city |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-02 |
Dagoberto Nuñez |
nunezdagoberto730@gmail.com |
833 basswood ln iowa city |
Johnson |
IA |
Darwin salgado |
Ramon nuñez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dagoberto Nuñez |
nunezdagoberto730@gmail.com |
Yo mismo |
Iowa city |
Johnson |
IA |
Darwin Salgado |
Ramon nuñez |
Signed |
1979 |
2024-01-08 14:59 |
Anonymous (not verified) |
94.188.205.167 |
Nathan Troendle |
Proprietorship |
Lansing Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-05 |
Nathan Troendle |
darrele@ciains.biz |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Troendle |
darrele@ciains.biz |
self |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1502 |
2023-03-07 12:40 |
Anonymous (not verified) |
94.188.205.177 |
Joseph Martin |
Limited Liability Company |
P O Box 277 Lime Springs, 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. |
2022-04-18 |
Joseph Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
Member |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chrus Fye |
Signed |
1503 |
2023-03-07 12:45 |
Anonymous (not verified) |
94.188.205.177 |
Al's Roofing LLC |
Limited Liability Company |
P O Box 277 Lime Springs, 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. |
2022-04-18 |
John Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |