1276 |
2022-08-19 13:43 |
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. |
2022-08-19 |
Allen Aldridge |
allenaldridge73@yahoo.com |
Davenport |
Scott |
Iowa |
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 |
Scott |
Iowa |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1283 |
2022-08-25 10:23 |
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. |
2022-08-25 |
Christopher Payne |
service@paynedrywall.com |
Davenport |
Scott |
Iowa |
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 |
Scott |
Iowa |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1297 |
2022-09-07 09:36 |
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. |
2022-09-07 |
Dagoberto Nunez |
nunezdogoberto730@gmail.com |
Iowa City |
Johnson |
Iowa |
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 |
Scott |
Iowa |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1298 |
2022-09-07 09:58 |
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. |
2022-09-07 |
Derek Sherwodd |
sherwoodpainting@hotmail.com |
Davenport |
Scott |
Iowa |
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 |
Scott |
Iowa |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1313 |
2022-09-19 11:03 |
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. |
2022-09-19 |
Merle Broihier |
premiere_pd_llc@yahoo.com |
Bettendorf |
Scott |
Iowa |
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 |
Scott |
Iowa |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
674 |
2021-10-15 09:43 |
Anonymous (not verified) |
173.29.63.3 |
Peter Hawley |
Proprietorship |
524 n galena ave, Wyoming Illinois 61491 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-15 |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Wyoming |
Stark |
Illinois |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Self |
Wyoming |
Stark |
IL |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
182 |
2020-06-11 14:18 |
Anonymous (not verified) |
173.29.64.73 |
Diamond Builders of Davenport INC |
Proprietorship |
14358 275th St, Long grove, IA 52756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
Paula Woods |
paulawoods@diamond-builders.com |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Green |
tyler@porterinsuranceinc.com |
Insurance Agent |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
523 |
2021-05-17 21:46 |
Anonymous (not verified) |
173.29.90.123 |
Nick keppy |
Proprietorship |
2103 e Lombard 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. |
2021-05-17 |
Nick keppy |
keppylawncare@gmail.com |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca Hein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick keppy |
keppylawncare@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca hein |
Signed |
1094 |
2022-05-12 09:26 |
Anonymous (not verified) |
173.30.136.186 |
Missy Weber |
Limited Liability Company |
4290 Spring Creek Road Jesup, Iowa 50648 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-12 |
Melissa Weber |
mweber@cardinalcapital.us |
JESUP |
Black Hawk |
Iowa |
Sharon Woodson |
Shelly Donlon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Weber |
mweber@cardinalcapital.us |
partner/husband |
Jesup |
Blackhawk |
Iowa |
Janice Weber |
Laverne Weber |
Signed |
893 |
2022-02-03 16:17 |
Anonymous (not verified) |
173.30.138.148 |
Your Cleaning Solution LLC |
Limited Liability Company |
P.O. Box 176 Gilbertville IA 50634 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-03 |
Tricia Olson |
toyourcleaningsolution@yahoo.com |
Gilbertville |
Black Hawk |
Ia |
Michael Olson |
Kathy Heilig |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tricia Olson |
toyourcleaningsolution@yahoo.com |
Same person |
Gilbertville |
Black Hawk |
Ia |
Michael Olson |
Kathy Heilig |
Signed |
319 |
2020-11-16 19:24 |
Anonymous (not verified) |
173.30.37.132 |
Nathan Wright |
Proprietorship |
500 2nd Avenue, Charles City, Iowa 50616 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-16 |
Nathan Robert Wright |
nrwright85@yahoo.com |
Charles City |
Floyd |
Iowa |
Jeff Wright |
Marsha Wright |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Robert Wright |
nrwright85@yahoo.com |
Self |
Charles City |
IA |
IA |
Jeff Wright |
Marsha Wright |
Signed |
273 |
2020-10-05 13:57 |
Anonymous (not verified) |
173.30.54.139 |
Jackson Exteriors |
Proprietorship |
705 Cherry Avenue Woodward,ia 50276 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-05 |
Lucas Jackson |
ljajackson41977@gmail.com |
Woodward |
IA |
United States |
Cody Roth |
Dustin Perry |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Jackson |
ljajackson41977@gmail.com |
Owner |
Woodward |
Dallas |
United States |
Cody Roth |
Dustin perry |
Signed |
1295 |
2022-09-05 20:39 |
Anonymous (not verified) |
173.30.59.248 |
Guide LLC |
Limited Liability Company |
1655 Ashton Place, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-05 |
Braydon Fisher |
braydonfisher28@gmail.com |
Dubuque |
IA |
United States |
Conner Cole |
Alec Kolander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Braydon Fisher |
braydonfisher28@gmail.com |
Owner |
Dubuque |
IA |
United States |
Conner Cole |
Alex Kolander |
Signed |
1145 |
2022-06-07 11:14 |
Anonymous (not verified) |
173.30.72.62 |
Swifty Enterprises |
Limited Liability Company |
1134 Capri Drive NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-07 |
Daniel Tabaka |
dmtabaka1@gmail.com |
Cedar Rapids |
Linn |
IA |
Wilma Janacek |
Fredrick Janacek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Tabaka |
dmtabaka1@gmail.copm |
Self |
Cedar Rapids |
Linn |
IA |
Wilma Janacek |
Fredrick Janacek |
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 |
875 |
2022-01-31 11:00 |
Anonymous (not verified) |
173.31.102.93 |
Jhk Construction LLC |
Limited Liability Company |
6203 Casey Ct NE cedar Rapids Iowa 52411 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-31 |
Edward Charles Loehr |
jhkcostruction10@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Leanne M Loehr |
Autumn G Loehr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jhk Construction LLC |
jhkconstruction10@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Leanne M Loehr |
Autumn G Loehr |
Signed |
452 |
2021-03-26 07:30 |
Anonymous (not verified) |
173.31.109.49 |
Rogers Concrete Construction |
Partnership |
22802 County Rd E34 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-26 |
Alexander Olah |
aolah43@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Robin Marie Kane |
Augies Rodrigez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Johnson |
kevinjohnson@libertymutual.com |
Insurance Agent |
Appleton |
Outagamie |
Wisconsin |
Robin Marie Kane |
Augie Rodrigez |
Signed |
62 |
2020-02-17 06:55 |
Anonymous (not verified) |
173.31.111.29 |
Pa's Construction LLC |
Limited Liability Company |
2350 Glass Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-17 |
Gregory Daniel Saunders |
gsaunders.pas@gmail.com |
CEDAR RAPIDS |
IOWA |
United States |
Laura Sturm |
Chad Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Walt Cheney |
Mike Broghammer |
Signed |
871 |
2022-01-29 15:43 |
Anonymous (not verified) |
173.31.116.134 |
West cleaning |
Proprietorship |
8925 Cascade Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-29 |
Fata Omerovic |
fataomerovic@msn.com |
West Des Moines |
IA |
Iowa |
Semir Omerovic |
Samir Omerovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fata Omerovic |
fataomerovic@msn.com |
Same person |
West Des Moines |
IA |
Iowa |
Semir Omerovic |
Samir Omerovic |
Signed |
168 |
2020-05-28 11:29 |
Anonymous (not verified) |
173.31.147.225 |
RECYCLED SPIRITS LLC |
Limited Liability Company |
43 ANN STREET MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-28 |
LACEY LAAKE |
BLAMB@SPENCERSCHOOLS.ORG |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LACEY LAAKE |
BLAMB@SPENCERSCHOOLS.ORG |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
169 |
2020-05-28 11:31 |
Anonymous (not verified) |
173.31.147.225 |
RECYCLED SPIRITS LLC |
Limited Liability Company |
43 ANN ST MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-28 |
BETH LAMB |
BLAMB@SPENCERSCHOOLS.ORG |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BETH LAMB |
BLAMB@SPENCERSCHOOLS.ORG |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
179 |
2020-06-09 11:22 |
Anonymous (not verified) |
173.31.147.225 |
SAUL GUERARA MEZA |
Proprietorship |
26 WESTVIEW DRIVE APT 5 MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-21 |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
219 |
2020-07-31 08:49 |
Anonymous (not verified) |
173.31.147.225 |
JOHN RUPP |
Proprietorship |
3110 TYLER AVENUE HARTLEY IA 51346 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-30 |
JOHN P RUPP |
THEELECTRICIANLLC@OUTLOOK.COM |
HARTLEY |
OBRIEN |
IOWA |
TAMI KLEIN |
KRIS WALKER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHN P RUPP |
THEELECTRICIANLLC@OUTLOOK.COM |
SELF |
HARTLEY |
OBRIEN |
IA |
TAMI KLEIN |
KRIS WALKER |
Signed |
327 |
2020-11-25 10:38 |
Anonymous (not verified) |
173.31.147.225 |
CASEY KYLE |
Proprietorship |
1505 9TH ST MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
CASEY KYLE |
JOEL@WALKERINSURANCEIA.COM |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CASEY KYLE |
JOEL@WALKERINSURANCEIA.COM |
SELF |
MILFORD |
DISCKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
342 |
2020-12-28 10:19 |
Anonymous (not verified) |
173.31.147.225 |
SAUL GUEVARA MEZA |
Proprietorship |
26 WESTVIEW DRIVE APARTMENT 5 MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-22 |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNG WIRTH |
Signed |
344 |
2020-12-28 11:31 |
Anonymous (not verified) |
173.31.147.225 |
JEFFREY GOETZINGER |
Proprietorship |
2112 ITHACA AVE SPIRIT LAKE IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-22 |
JEFFREY GOETZINGER |
WALKERINSURANCE@MCHSI.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JEFFREY GOETZINGER |
WALKERINSURANCE@MCHSI.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
357 |
2021-01-12 09:56 |
Anonymous (not verified) |
173.31.147.225 |
SKYLAR INGRAHAM |
Proprietorship |
903 9TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-12 |
SKYLAR INGRAHAM |
18SINGRAHA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SKYLAR INGRAHAM |
18SINGRAHA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
364 |
2021-01-14 13:46 |
Anonymous (not verified) |
173.31.147.225 |
JMAHER LLC |
Limited Liability Company |
907 4TH AVE 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. |
2021-01-14 |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
409 |
2021-02-18 16:35 |
Anonymous (not verified) |
173.31.147.225 |
MATTHEW MYHRE DBA GUNS GALORE |
Proprietorship |
2329 220TH AVE MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-18 |
MATTHEW MYHRE |
MYHRE3063@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATTHEW MYHRE DBA GUNS GALORE |
MYHRE3063@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
416 |
2021-03-02 10:33 |
Anonymous (not verified) |
173.31.147.225 |
TJ NAIG DBA NAIG CONSULTING |
Proprietorship |
PO BOX 678 ARNOLDS PARK IA 51331 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-25 |
TJADEN NAIG |
TJADENNAIG@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JOE LORING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TJADEN NAIG |
TJADENNAIG@GMAIL.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JOE LORING |
Signed |
475 |
2021-04-13 19:19 |
Anonymous (not verified) |
173.31.147.225 |
COAST TO COAST MILLWRIGHT LLC |
Limited Liability Company |
2909 HWY 71 AND 9 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-05 |
JANIE CANTU |
JOEL@WALKERINSURANCEIA.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JANIE CANTU |
janiecantu433@outlook.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
476 |
2021-04-13 19:23 |
Anonymous (not verified) |
173.31.147.225 |
COAST TO COAST MILLWRIGHT LLC |
Limited Liability Company |
2909 HWY 71 AND 9 SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-04-05 |
ADALBERTO CANTU |
JOEL@WALKERINSURANCEIA.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
ADALBERTO CANTU |
janiecantu433@outlook.com |
SELF-MEMBER |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
498 |
2021-04-27 12:54 |
Anonymous (not verified) |
173.31.147.225 |
TYREL KINKADE DBA: KINKADE CONSTRUCTION |
Proprietorship |
2289 165TH ST UNIT 10D |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-21 |
TYREL KINKADE |
hogtyd97@yahoo.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL KINKADE |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
512 |
2021-05-11 13:12 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
JEFF CACEK |
JEFF@RUTHVENROCKS.COM |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JEFF CACEK |
joel@walkerinsuranceia.com |
MEMBER |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
513 |
2021-05-11 13:14 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
KEITH CACEK |
KEITH@RUTHVENROCKS.COM |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEITH CACEK |
joel@walkerinsuranceia.com |
MEMBER |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
514 |
2021-05-11 13:16 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
MATT CACEK |
MATT@RUTHVENROCKS.COM |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT CACEK |
joel@walkerinsuranceia.com |
MEMBER |
MILFORD |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
749 |
2021-11-15 16:05 |
Anonymous (not verified) |
173.31.148.43 |
CHAMONE SWITZER |
Proprietorship |
PO BOX 72 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. |
2021-11-15 |
CHAMONE SWITZER |
CHAMONE.SWITZER@GMAIL.COM |
FOSTORIA |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNG WIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHAMONE SWITZER |
CHAMONE.SWITZER@GMAIL.COM |
SELF |
FOSTORIA |
IA |
United States |
TAMI KILEIN |
JENNIFER YOUNGWIRTH |
Signed |
783 |
2021-12-08 10:25 |
Anonymous (not verified) |
173.31.148.43 |
Nick Larsen |
Proprietorship |
1305 7th St. Milford, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-08 |
Nick Larsen |
larsennick77@gmail.com |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Larsen |
joel@walkerinsuranceia.com |
Self |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
790 |
2021-12-14 10:59 |
Anonymous (not verified) |
173.31.148.43 |
SILVER LAKE ACCOUNTING LLC |
Limited Liability Company |
178 W BAY RD |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-13 |
DARYA GAY |
DGAY@SILVERLAKEACCOUNTING.CPA |
LAKE PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DARYA GAY |
DGAY@SILVERLAKEACCOUNTING.CPA |
SELF |
LAKE PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
792 |
2021-12-14 13:18 |
Anonymous (not verified) |
173.31.148.43 |
BLUE WAVE SETTLEMENT LLC |
Limited Liability Company |
1205 H AVENUE MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-14 |
SHANNON NORTON |
NOERTONSHANNON@YAHOO.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BLUE WAVE SETTLEMENT LLC |
NORTONSHANNON@YAHOO.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
1026 |
2022-04-01 14:53 |
Anonymous (not verified) |
173.31.148.43 |
ARMANDO RESENDEZ |
Proprietorship |
202 S 13TH ST APT #8 ESTHERVILLE, IA 51334 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-01 |
ARMANDO RESENDEZ |
joel@walkerinsuranceia.com |
Estherville |
EMMET |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ARMANDO RESENDEZ |
joel@walkerinsuranceia.com |
SELF |
Estherville |
EMMET |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1040 |
2022-04-12 09:36 |
Anonymous (not verified) |
173.31.148.43 |
PAPA'S SMOKIN MEAT |
Proprietorship |
1940 147TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-12 |
KEITH MORISTON |
PAPASSMOKINMEAT@GMAIL.COM |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEITH MORISTON |
PAPASSMOKINMEAT@GMAIL.COM |
SELF |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1041 |
2022-04-12 09:39 |
Anonymous (not verified) |
173.31.148.43 |
PAPA'S SMOKIN MEAT |
Proprietorship |
1940 147TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-12 |
ROXANNE MORISTON |
MORISTON2@YAHOO.COM |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ROXANNE MORISTON |
MORISTON2@YAHOO.COM |
SELF |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1086 |
2022-05-03 12:32 |
Anonymous (not verified) |
173.31.148.43 |
SHAWN BAIRD |
Proprietorship |
PO BOX 44 307 MEADOW ST ROYAL, IA 51357 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-02 |
SHAWN BAIRD |
FLOORMAN3872@GMAIL.COM |
ROYAL |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHAWN BAIRD |
FLOORMAN3872@GMAIL.COM |
SELF |
ROYAL |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1136 |
2022-05-31 13:46 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI BURRITO COMPANY LLC |
Limited Liability Company |
39502 710TH ST LAKEFIELD, MN 56105 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
SELF |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
564 |
2021-07-08 13:33 |
Anonymous (not verified) |
173.31.156.49 |
SS Docks |
Limited Liability Company |
P.O. Box 561 Okoboji IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-07-08 |
Jason Andrew Snow |
snowjas75@gmail.com |
Lake Park |
Dickinson |
IA |
Amber Egesdal |
Vickie Walters |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
SS Docks |
snowjas75@gmail.com |
Owner |
Okoboji |
Dickinson |
IA |
Amber Egesdal |
Vickie Walters |
Signed |
121 |
2020-04-14 15:11 |
Anonymous (not verified) |
173.31.176.75 |
Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Michele E Collison |
darmstad48@aol.com |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
548 |
2021-06-24 22:08 |
Anonymous (not verified) |
173.31.28.69 |
Brown's Window Cleaning +PLUS |
Proprietorship |
700 11th Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-24 |
Lawrence Brown |
brownswindowcleaningplus@gmail.com |
Altoona |
Iowa |
United States |
Jason Alderman |
Colette Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lawrence Brown |
brownswindowcleaningplus@gmail.com |
Self |
Altoona |
Iowa |
United States |
Jason Alderman |
Colette Evans |
Signed |
1095 |
2022-05-12 13:20 |
Anonymous (not verified) |
173.31.29.53 |
Leaf cutter protection |
Limited Liability Company |
4146 East 23rd Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-05-12 |
Gideon Lagat |
gsaina78@gmail.com |
Des Moines |
IA |
United States |
Priscilla saina |
Cosmas nyaika |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark rond |
mbond@leaffilter.com |
Regional installation Manager |
Grimes |
Polk |
Iowa |
Priscilla saina |
Cosmas nyaika |
Signed |
237 |
2020-08-18 19:01 |
Anonymous (not verified) |
174.125.150.45 |
Wdflyers llc |
Limited Liability Company |
453 hwy 1183 Simmesport la 71369 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-25 |
Donald Anderson |
sugarscoot@yahoo.com |
Simmesport |
Avoyelles |
Louisiana |
kolter coco |
wendy coco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Donald Anderson |
sugarscoot@yahoo.com |
self |
Simmesport |
Avoyelles |
Louisiana |
kolter coco |
wendy coco |
Signed |
266 |
2020-09-21 18:08 |
Anonymous (not verified) |
174.126.94.77 |
Club Fantasy Inc. |
Limited Liability Company |
P.O. Box 5115 Sioux City Iowa 51102 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-21 |
Curtis A. Behr |
cacbehr@aol.com |
Sioux City |
Woodbury |
Iowa |
Carter Vahle |
Dawn Meyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Curtis A. Behr |
cacbehr@aol.com |
Self |
Sioux City |
Woodbury |
Iowa |
Carter Vahle |
Dawn Meyer |
Signed |
176 |
2020-06-07 08:23 |
Anonymous (not verified) |
174.16.51.128 |
TrueFood LLC |
Limited Liability Company |
2055 Nature Ave Stanton IA 51573 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-24 |
Brian Barkman |
brian.barkman@truefood.farm |
Georgetown |
Williamson |
Texas |
Wanda Barkman |
Chelsea Church |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Barkman |
brian.barkman@truefood.farm |
TrueFood LLC is owned by agent |
Stanton |
Montgomery |
IA |
Wanda Barkman |
Chelsea Church |
Signed |
1008 |
2022-03-25 15:15 |
Anonymous (not verified) |
174.192.130.230 |
Hill's Rehab &Landscape L.L.C |
Limited Liability Company |
3717 15th ave Moline Illinois 61365 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-25 |
Joshua hill |
joshuajameshill79@gmail.com |
Moline |
Rock Island |
Illinois |
Lindsay erin Hill |
NICOLE ann lear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua james hill |
joshuajameshill79@gmail.com |
President |
Moline |
Rock Island |
Illinois |
Lindsay Erin Hill |
NIcole ann lear |
Signed |
954 |
2022-03-08 11:07 |
Anonymous (not verified) |
174.192.138.191 |
Duwa Waterproofing |
Limited Liability Company |
729 Deer View Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-08 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Tiffin |
Johnson |
Iowa |
Chad Cooper |
Curtis Sexton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
President |
Tiffin |
Johnson |
Iowa |
Chad Cooper |
Curtis Sexton |
Signed |
992 |
2022-03-21 19:42 |
Anonymous (not verified) |
174.192.66.11 |
Christopher Binns |
Proprietorship |
1324 Grand Ave, Davenport, IA 52803 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-21 |
Christopher Binns |
christophersbinns@gmail.com |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Binns |
christophersbinns@gmail.com |
same |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
323 |
2020-11-19 10:55 |
Anonymous (not verified) |
174.192.67.61 |
Connor trucking |
Proprietorship |
2791 270th st Dewitt ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-19 |
Richard Todd Connor |
connortrucking@hotmail.com |
Dewitt |
Clinton |
Iowa |
Michelle Connor |
Josh connor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Todd Connor |
connortruckin@hotmail.com |
Self |
Dewitt |
Clinton |
Iowa |
Michelle Connor |
Josh Connor |
Signed |
1267 |
2022-08-17 14:11 |
Anonymous (not verified) |
174.192.75.162 |
Elijah wyant |
Proprietorship |
708 1/2 w 3rd st davenport ia 52802 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-17 |
Elijah wyant |
Aidenwyant@gmail.com |
Davenport |
Scott |
Iowa |
Jake laxton |
Courtney sanders |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elijah wyant |
Aidenwyant@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Jake laxton |
Courtney sanders |
Signed |
990 |
2022-03-21 15:18 |
Anonymous (not verified) |
174.192.80.32 |
Chris Binns |
Proprietorship |
1324 Grand Ave Davenport, IA 52803 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-21 |
Christ Binns |
christophersbinns@gmail.com |
Davenpory |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Binns |
christophersbinns@gmail.com |
Same |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
1333 |
2022-10-13 14:01 |
Anonymous (not verified) |
174.192.85.141 |
Terry Smith |
Proprietorship |
1028 14th Avenue Fulton il |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-14 |
Terry Smith |
terry1270smith@gmail.com |
Fulton |
IL |
United States |
Angela Smith |
Tracey Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Smith |
terry1270smith@gmail.com |
Wife |
Fulton |
IL |
United States |
Angie Smith |
Tracey smith |
Signed |
820 |
2022-01-03 10:41 |
Anonymous (not verified) |
174.195.193.112 |
Wolverine Construction LLC |
Limited Liability Company |
467 s 84th street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-03 |
steffan sheehey |
steffanrobert@gmail.com |
West Des Moines |
Dallas |
IA |
Christopher Sheehey |
Taylor Lyman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
steffan sheehey |
steffanrobert@gmail.com |
Manager |
West Des Moines |
Dallas |
IA |
Christopher Sheehey |
Marcus Hatcher |
Signed |
1028 |
2022-04-02 11:01 |
Anonymous (not verified) |
174.198.64.100 |
Great-Dain Htg/Ac & Plumbing |
Proprietorship |
1616 Maple Rd. Harlan, Iowa 51537 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-02 |
Richard Nee |
great-dain@hotmail.com |
Harlan |
Shelby |
Iowa |
Doug Clark |
Jesse Nee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Nee |
great-dain@hotmail.com |
Self |
Harlan |
Shelby |
Iowa |
Doug Clark |
Jesse Nee |
Signed |
1396 |
2022-12-19 18:35 |
Anonymous (not verified) |
174.198.65.20 |
Flyover Productions LLC |
Limited Liability Company |
300 S Clinton St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-19 |
Richard A Redfern |
richredfern3@gmail.com |
Iowa City |
IA |
United States |
Susan Redfern |
Aditi Reddy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Redfern |
richredfern3@gmail.com |
Owner of company |
Iowa City |
Iowa |
United States |
Susan Redfern |
Aditi Reddy |
Signed |
1302 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
1303 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
1304 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
719 |
2021-11-05 13:48 |
Anonymous (not verified) |
174.198.66.202 |
James Johnson Ace Floor Guys |
Proprietorship |
521 29th st NE Cedar Rapids, Ia 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-13 |
James Johnson |
acefloorguysia@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Johnson |
acefloorguysia@gmail.com |
Self Employed |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
725 |
2021-11-05 14:32 |
Anonymous (not verified) |
174.198.66.202 |
Jay Schulte |
Proprietorship |
7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Jay Schulte |
schultejay@Hotmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Schulte |
schultejay@hotmail.com |
Self Employed |
Cedar Rapids |
Linn |
Ia |
Sarah Coberley |
Heather Howell |
Signed |
726 |
2021-11-05 14:39 |
Anonymous (not verified) |
174.198.66.202 |
John Stoltzfus JM Tile LLC |
Limited Liability Company |
Wellman, Ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-19 |
John Stoltzfus |
installation@bachmeiercarpetone.com |
Wellman |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Stoltzfus |
installation@bachmeiercarpetone.com |
Self |
Wellman |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
727 |
2021-11-05 14:46 |
Anonymous (not verified) |
174.198.66.202 |
Bret Swift Swift Enterprises |
Proprietorship |
2240 Coldstream Drive NE, Cedar Rapids, Ia 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-13 |
Brett Swidt |
swiftenterprises@me.com |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bret Swift |
swiftenterprises@me.com |
Self Employed |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
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 |
1139 |
2022-06-02 08:49 |
Anonymous (not verified) |
174.198.67.34 |
Gentry Hardware Incorporated |
Partnership |
308 5th Street; Rockwell City, IA 50579 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-02 |
Emily Gentry |
emilygentry1127@gmail.com |
Rockwell City |
Calhoun |
IA |
Ben Rand |
Karie Knouf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emily Gentry |
emilygentry1127@gmail.com |
Owner |
Rockwell City |
Calhoun |
IA |
Ben Rand |
Karie Knouf |
Signed |
1195 |
2022-07-08 13:24 |
Anonymous (not verified) |
174.198.67.66 |
Chapas Construction |
Limited Liability Company |
6424 Roseland Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Polibio Raul Chapa Farez |
chapasconstructionllc@gmail.com |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Polibio Raul Chapa |
chapasconstructionllc@gmail.com |
President |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
650 |
2021-09-22 20:46 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services |
Limited Liability Company |
6285 n 67 ave w baxter iowa 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
651 |
2021-09-22 21:05 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services LLC |
Limited Liability Company |
6285 n 67 ave w. BAXTER IOWA 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
1300 |
2022-09-07 16:38 |
Anonymous (not verified) |
174.198.70.216 |
Phillip Phelps |
Proprietorship |
2900 4th St Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-07 |
Phillip Phelps |
phillipphelps8732@yahoo.com |
Marion |
Linn |
Iowa |
Kaitlin Davidson |
Kevin Phelps |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Phillip Phelps |
phillipphelps8732@yahoo.com |
Self |
Marion |
Linn |
Iowa |
Kaitlin Davidson |
Kevin Phelps |
Signed |
1069 |
2022-04-26 08:39 |
Anonymous (not verified) |
174.198.72.171 |
GR Roofing |
Proprietorship |
802 E County Line Rd Lot 137, Des Moines, Ia 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-26 |
Eleazar Guzman-Rios |
emmanuelgscop.1425@gmail.com |
Des Moines |
Polk |
Iowa |
Manny Socop |
Julio Andrew |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eleazar Guzman-Rios |
emmanuelgscop.1425@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Manny Socop |
Julio Andrews |
Signed |
1070 |
2022-04-26 09:35 |
Anonymous (not verified) |
174.198.72.171 |
Boyz Roofing LLC |
Limited Liability Company |
802 E County Lane Rd Lot 25 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-26 |
Cupertino Rodriguez Hernandez |
christopherrodriguez091889@gmail.com |
Des Moines |
Polk |
Iowa |
Yoselin Morales |
Manny Sokop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cupertino Rodriguez Hernandez |
christopherrodriguez091889@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Yoselin Morales |
Manny Sokop |
Signed |
446 |
2021-03-23 12:39 |
Anonymous (not verified) |
174.198.72.209 |
Final Finish llc |
Limited Liability Company |
3824 12th st Des Moines Iowa 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-23 |
Wesley Robert Detman |
wesdet@gmail.com |
Drs Moines |
Polk |
Iowa |
Leah Laxton |
Lucas Laxton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wesley Robert Detman |
wesdet@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leah Laxton |
Lucas Laxton |
Signed |
449 |
2021-03-25 10:53 |
Anonymous (not verified) |
174.198.73.94 |
A&F Painting llc |
Limited Liability Company |
411 E Dunham ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-25 |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Des Moines |
Polk |
Iowa |
Alfonzo Afanador |
Noemi Afanador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Alfonzo Alfanador |
Noemi Alfanador |
Signed |
1427 |
2023-01-23 10:53 |
Anonymous (not verified) |
174.198.74.123 |
Landon Manfull |
Proprietorship |
51909 hwy 210 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Landon Manfull |
landonmanfull1@gmail.com |
Slater |
Story |
Iowa |
Landon Manfull |
Landon Manfull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Landon Manfull |
landonmanfull1@gmail.com |
Myself |
Slater |
Story |
Iowa |
Landon Manfull |
Landon Manfull |
Signed |
929 |
2022-02-18 09:18 |
Anonymous (not verified) |
174.198.74.217 |
LA Painting LLC |
Limited Liability Company |
6460 Merle Hay Rd unit 222 Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-18 |
Adolfo Rodriguez Afanador |
adolforodriguez11@yahoo.com |
Johnston |
Polk |
Iowa |
Esequiel Rodriguez |
Karina Valdez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adolfo Rodriguez Afanador |
adolforodriguez11@yahoo.com |
Owner |
Johnston |
Polk |
Iowa |
Esequiel Rodriguez |
Karina Valdez |
Signed |
414 |
2021-02-28 15:32 |
Anonymous (not verified) |
174.198.75.211 |
Charlie Christian Hutt |
Proprietorship |
609 E. main 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. |
2021-01-29 |
Charlie Christian Hutt |
bmxican_04@hotmail.com |
Brooklyn |
poweshiek |
IA |
gene shafbough |
hannah hutt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charlie Christian Hutt |
bmxican_04@hotmail.com |
sole |
Brooklyn |
poweshiek |
IA |
gene shafbough |
hannah hutt |
Signed |
785 |
2021-12-09 09:15 |
Anonymous (not verified) |
174.198.75.71 |
Daniel Vega camacho |
Proprietorship |
2415 river ,meadows drive Des Moines Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-09 |
Daniel Vega camacho |
dvega50265@gmail.com |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Vega camacho |
dvega50265@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
623 |
2021-08-30 15:03 |
Anonymous (not verified) |
174.198.77.231 |
Joe Dawson |
Proprietorship |
1088, Dogwood Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-30 |
Joe R Dawson |
joerdawson@gmail.com |
Coon Rapids |
IA |
United States |
Linda Doran |
Megan Specht |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Joe R Dawson |
joerdawson@gmail.com |
Owner |
Coon Rapids |
IA |
United States |
Linda Doran |
Megan Specht |
Signed |
930 |
2022-02-20 13:24 |
Anonymous (not verified) |
174.198.77.72 |
2Maros Excavating Company |
Limited Liability Company |
204 West First Street, Saint Donatus, Iowa 52071 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-20 |
Steve Maro |
2marosmfg@gmail.com |
Saint Donatus |
Jackson |
Iowa |
Brenda McKenna |
Joe McKenna |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Maro |
2marosmfg@gmail.com |
Owner |
Saint Donatus |
Jackson |
Iowa |
Brenda McKenna |
Joe McKenna |
Signed |
313 |
2020-11-11 20:35 |
Anonymous (not verified) |
174.198.78.148 |
Wilson Snow Maintenance |
Proprietorship |
3518 183rd Avenue, Carlisle, Iowa 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. |
2020-11-11 |
Bruce E. Wilson |
bewilson83@gmail.com |
Carlisle |
Warren |
Iowa |
Kristen Wilson |
Garett Wilson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Bruce Wilson |
bewilson83@gmail.com |
self |
Carlisle |
Warren |
Iowa |
Kristen Wilson |
Garett Wilson |
Signed |
404 |
2021-02-16 13:30 |
Anonymous (not verified) |
174.198.79.179 |
Topline Painting llc |
Limited Liability Company |
1603 e 32nd st Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-16 |
Michael nunez |
toplinepaintingiowa@gmail.com |
Des Moines |
Polk |
Iowa |
Jimmy nunez |
Jose Nunez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael nunez |
toplinepaintingiowa@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Jimmy nunez |
Jose nunez |
Signed |
862 |
2022-01-27 12:02 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction,LLC |
Limited Liability Company |
4508 Hiawatha Ave NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Michael Allen Becker |
mike4bbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Brother/partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
863 |
2022-01-27 12:13 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction llc |
Limited Liability Company |
4508 Hiawatha Ave ne Cedar Rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Allen Becker |
mike4bbc@gmail.com |
Brother/Partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
325 |
2020-11-23 11:14 |
Anonymous (not verified) |
174.198.82.169 |
Dan davidson |
Limited Liability Company |
21Lincoln Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-11-22 |
Daniel Lee davidson |
unitedremodelingdd@gmail.com |
Palo |
Linn |
IA |
Daniel Lee davidson |
Daniel Lee davidson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Daniel Lee davidson |
unitedremodelingdd@gmail.com |
Owner |
Palo |
Linn |
IA |
Daniel Lee davidson |
Daniel Lee davidson |
Signed |
774 |
2021-11-29 12:28 |
Anonymous (not verified) |
174.198.82.208 |
Demetrio's Construction |
Proprietorship |
2018 Heights Ave Sioux City, IA 51104 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-29 |
Guillermo Demetrio |
moralesdalia44@yahoo.com |
Sioux City |
Woodbury |
Iowa |
Dalia E. Morales Galvez |
Vanessa Topete |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Guillermo Demetrio |
moralesdalia44@yahoo.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Dalia Morales Galvez |
Vanessa Topete |
Signed |
328 |
2020-11-26 12:28 |
Anonymous (not verified) |
174.198.82.38 |
Duke millwright doing business as duke & sons |
Limited Liability Company |
3264 e Payton ave Des Moines iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-11-26 |
Jeremiah duke |
jpduke24.7.365@gmail.com |
Des Moines |
Polk county |
Iowa |
Daniel Patrick Hemann |
Nikki Marie Harvey |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Diana duke |
dukemillwright@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Nikki Marie Harvey |
Daniel Patrick Hemann |
Signed |
1101 |
2022-05-13 12:55 |
Anonymous (not verified) |
174.199.102.54 |
Daniel Blanco |
Proprietorship |
1403 2nd Ave S |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-13 |
Daniel Blanco |
chindan77@yahoo.com |
Ft Dodge |
Webster |
IA |
Vanessa Blanco |
Elva Castañeda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Blanco |
chindan77@yahoo.com |
Self |
Ft Dodge |
Webster |
IA |
Vanessa Blanco |
Elva Castañeda |
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 |
970 |
2022-03-14 14:08 |
Anonymous (not verified) |
174.199.79.176 |
Friends Transportation Services LLC |
Limited Liability Company |
6010 Creston Ave Unit 26, Des Moines, IA 50321 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Mohammed Dood |
mohedali777@hotmail.com |
Des Moines |
Polk |
Iowa |
Leigh Laven |
Geoff Matlock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mohammed Dood |
mohedali777@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leigh Laven |
Geoff Matlock |
Signed |
816 |
2021-12-30 09:56 |
Anonymous (not verified) |
174.199.83.133 |
Michael Fales |
Proprietorship |
1987 180th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-30 |
Michael Lee Fales |
Chubby__69@hotmail.com |
Canby |
Yellow Medicine |
Minnesota |
Tori Fales |
Jean Fales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Lee Fales |
Chubby__69@hotmail.com |
Owner |
Canby |
Yellow Medicine |
Minnesota |
Tori Fales |
Jean Fales |
Signed |
1212 |
2022-07-19 10:15 |
Anonymous (not verified) |
174.209.40.210 |
James holmes |
Proprietorship |
866 40th Ave bettendorf IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-19 |
James holmes |
jrholmes1958@gmail.com |
Moline |
Rock island |
Il |
Tiffani branham |
Cody dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaffilter north llc |
cdunbar@leaffilter.com |
Install manager |
Bettendorf |
Scott |
Ia |
Cody dunbar |
Tiffani branham |
Signed |
1128 |
2022-05-26 11:11 |
Anonymous (not verified) |
174.213.144.187 |
Leaf Filter |
Limited Liability Company |
3060 se grimes blvd suite 100-300 Grimes iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-24 |
Jason charlet |
jasonstreeservice2014@gmail.com |
Minburn |
Dallas |
Iowa |
Kami lillibridge |
Dale charlet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
N/a |
jasoncharlet703@gmail.com |
N/a |
N/a |
N/a |
N/a |
N/a |
N/a |
Signed |
1154 |
2022-06-14 00:27 |
Anonymous (not verified) |
174.213.144.227 |
Arben Bahtirovic |
Partnership |
3060 South East Grimes Blvd, Suite 100-300 Grimes, Iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-06-14 |
Arben Bahtirovic |
arben2002@gmail.com |
West Des Moines |
Polk |
IOWA |
Senida bahtirovic |
Mario mandic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arben Bahtirovic |
arben2002@gmail.com |
Contractor |
West Des Moines |
Polk |
IOWA |
Senida bahtirovic |
Marijo mandic |
Signed |
1370 |
2022-11-13 19:49 |
Anonymous (not verified) |
174.213.144.30 |
Iowa’s Gutter Specialist |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-21 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Patricia Reynolds |
Heather Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Patricia Marie Reynolds |
Heather Marie Halverson |
Signed |
825 |
2022-01-06 21:02 |
Anonymous (not verified) |
174.213.145.18 |
Two Brothers Tile llc |
Proprietorship |
1244 72nd St Windsor heights ia 50324 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-06 |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Owner |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
986 |
2022-03-18 16:46 |
Anonymous (not verified) |
174.213.145.90 |
Gonzalez Contractors LLC. |
Limited Liability Company |
150 NE 41st St Unit 109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-18 |
Elmer Gonzalez |
gonzalez922014@icloud.com |
Ankeny |
Polk |
IA |
Kassandra Gonzalez |
Jesus Gonaalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elmer Gonzalez |
gonzalez922014@icloud.com |
Owner |
Ankeny |
Polk |
IA |
Kassandra Gonzalez |
Jesus Gonzalez |
Signed |
374 |
2021-01-25 12:15 |
Anonymous (not verified) |
174.213.149.27 |
Vaughn Peyton |
Proprietorship |
3060 19th avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-25 |
Vaughn Peyton |
vaughnage173@hotmail.com |
Marion |
Iowa |
United States |
Ronald Bart Peyton |
Kristine Katherine Peyton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vaughn Peyton |
vaughnage173@hotmail.com |
Myself |
Marion |
Iowa |
United States |
Ronald Bart Peyton |
Kristine Katherine Peyton |
Signed |
331 |
2020-12-03 10:19 |
Anonymous (not verified) |
174.213.165.124 |
TTC Cleaning Services |
Limited Liability Company |
2155-230th St Marshalltown, IA. 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-03 |
Zachary Stephen Bolar |
zbolar80@gmail.com |
Marshalltown |
Marshall |
IA |
Brian Mason |
Casey Jesina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Stephen Bolar |
zbolar80@gmail.com |
Self |
Marshall |
Marshall |
IA |
Brian Mason |
Casey Jesina |
Signed |
1135 |
2022-05-31 12:06 |
Anonymous (not verified) |
174.215.227.133 |
Plagman Transportation |
Limited Liability Company |
1306 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. |
2022-05-31 |
Ryan Plagman |
rplagman@gmail.com |
Adel |
Dallas |
Ia |
Chris Christensen |
Jack Ruby |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Plagman |
rplagman@gmail.com |
Same |
Adel |
Dallas |
Ia |
Chris Christensen |
Jack Ruby |
Signed |
888 |
2022-02-03 14:40 |
Anonymous (not verified) |
174.215.230.111 |
Blakesley Enterprise |
Proprietorship |
609 Center St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-03 |
William Blakesley |
Blakesleyb@msn.com |
Reinbeck |
Iowa |
Iowa |
Nichelle Blakesley |
Christine Willis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Blakesley |
Blakesleyb@msn.com |
Owner |
Reinbeck |
Iowa |
Iowa |
Nichelle Blakesley |
Christine Willis |
Signed |
1435 |
2023-01-31 14:33 |
Anonymous (not verified) |
174.215.242.112 |
Premier builders |
Proprietorship |
1821 East Ridgeway |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-31 |
Edward Koch |
etkdbq@aol.com |
Waterloo |
IA |
United States |
Glenda mclarty |
Coen Koch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Koch |
etkdbq@aol.com |
Owner |
Waterloo |
IA |
United States |
Glenda Mclarty |
Coen Koch |
Signed |
1436 |
2023-02-01 11:53 |
Anonymous (not verified) |
174.215.242.112 |
Leaf home solutions |
Limited Liability Company |
1595 Georgetown Rd. Hudson, Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-01 |
Edward Koch |
etkdbq@aol.com |
Waterloo |
IA |
United States |
Glenda mclarty |
Coen Koch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian yurko |
byurko@leafhome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Brian Mako |
Matt kaulig |
Signed |
1437 |
2023-02-01 15:42 |
Anonymous (not verified) |
174.215.242.112 |
Safe step walk in tub of Minnesota |
Limited Liability Company |
7300 Washington Ave S. Eden prairie, MN 55344 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-01 |
Edward Koch |
etkdbq@aol.com |
Waterloo |
IA |
United States |
Glenda mclarty |
Coen Koch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James alley |
JAlley@safesteptub.com |
Vice president of production |
Eden prairie |
Hennepin |
MN |
Brent Jarvis |
Bruce illies |
Signed |
1029 |
2022-04-04 12:46 |
Anonymous (not verified) |
174.215.242.124 |
Bonnie Seely |
Proprietorship |
43 rainbow court se Cedar Rapids Iowa 52403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-04 |
Bonnie Elizabeth seely |
bseely4@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Mikaela Seely |
Noah seely |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bonnie Seely |
bseely4@gmail.com |
Self |
Cedar Rapids |
IA |
United States |
Mikaela Seely |
Noah Seely |
Signed |
935 |
2022-02-24 09:44 |
Anonymous (not verified) |
174.215.244.252 |
Cornejo Construction |
Limited Liability Company |
419 2nd St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-24 |
Bulmaro Cornejo |
cruzcornejo4314@gmail.com |
Perry |
Dallas |
Iowa |
Jose Cruz Cornejo Andrade |
Brenda Espinoza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bulmaro Cornejo |
cruzcornejo4314@gmail.com |
Owner |
Perry |
Dallas |
Iowa |
Jose Cruz Cornejo |
Brenda Espinoza |
Signed |
927 |
2022-02-17 16:22 |
Anonymous (not verified) |
174.215.244.78 |
Mike Benson dba Standard Drywall |
Proprietorship |
1713 w7th st. Waterloo iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Michael Arlyn Benson |
mikekimbenson@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Leesa Marie Wheeler |
Austin Michael Thorpe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Arlyn Benson |
mikekimbenson@gmail.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Leesa Marie Wheeler |
Austin Michael Thorpe |
Signed |
938 |
2022-02-25 15:21 |
Anonymous (not verified) |
174.215.247.215 |
Maria castillo |
Limited Liability Company |
2200 scott blvd #90 iowa city iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-25 |
Maria evangelina castillo moreno |
mariacastillo852@yahoo.com |
Iowa city |
Jonhson |
Iowa |
Maria castillo |
Emilio Castillo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maria evangelina castillo moreno |
mariacastillo852@yahoo.vom |
Work |
Iowa city |
Johnson |
Iowa |
Maria castillo |
Emilio Castillo |
Signed |
1118 |
2022-05-18 11:12 |
Anonymous (not verified) |
174.215.249.55 |
Nilson construction |
Proprietorship |
3219 bowdoin st Des Moines Iowa 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-18 |
Romel Edenilson saravia Aparicio |
romelsaravia5@gmail.com |
Des Moines |
Polk |
Iowa |
Alvaro camacho |
Ricardo Iyan campuzano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Romel edenilson saravia aparicio |
romelsaravia5@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Alvaro camacho |
Ricardo iyan campuzano |
Signed |
1246 |
2022-08-08 12:33 |
Anonymous (not verified) |
174.215.249.59 |
Dustin Rambo |
Proprietorship |
4570, Hunter St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-07 |
Dustin Lee Rambo |
dlrambo80@gmail.com |
Palo |
USA |
IA |
Matt Lytle |
Jason Achenbach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Rambo |
dlrambo80@gmail.com |
Self |
Palo |
USA |
IA |
Matt Lytle |
Jason Achenbach |
Signed |
1356 |
2022-11-02 08:21 |
Anonymous (not verified) |
174.215.249.84 |
Leaf home solutions |
Proprietorship |
1595 Georgetown Road, Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-02 |
Micheal Wills |
mwills5304@gmail.com |
Granger |
Polk |
IA |
Bryanna Wills |
Andrew Vannausdle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryanna Wills |
bryannawills725@gmail.com |
None |
Granger |
Polk |
IA |
Andrew Vannausdle |
Micheal Wills |
Signed |
1331 |
2022-10-11 13:17 |
Anonymous (not verified) |
174.216.2.52 |
Parceros Construction LLC |
Limited Liability Company |
2315 Landon Rd. Apt. 206 North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-11 |
Laura Garavito |
ldanielagaravitog@gmail.com |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura Garavito |
ldanielagaravitog@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
711 |
2021-11-04 13:07 |
Anonymous (not verified) |
174.216.69.18 |
Corey Gramowski |
Proprietorship |
2101 21st ST Emmetsburg IA 50536 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-04 |
Corey Gramowski |
gramowski@windstream.net |
Emmetsburg |
Palo Alto |
IA |
Frank Kliegl |
John Heddinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Gramowski |
gramowski@windstream.net |
Self |
Emmetsburg |
Palo Alto |
IA |
Frank Kliegl |
John Heddinger |
Signed |
218 |
2020-07-27 19:24 |
Anonymous (not verified) |
174.217.10.15 |
Bella Exteriors LLC |
Limited Liability Company |
2908 Elm St, West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-27 |
Nicholas Andersen |
nick@rightroofing.com |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Andersen |
nickande3564@gmail.com |
Self |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
93 |
2020-03-16 08:01 |
Anonymous (not verified) |
174.217.14.119 |
DOUBLE J CONTRACTING LLC |
Limited Liability Company |
18693 335TH LN, EARLHAM, IA 50072 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-16 |
JOSHUA D OSCARSON |
double-j-llc@outlook.com |
EARLHAM |
DALLAS |
IOWA |
Tim Hudson |
Kevin Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas Oscarson |
double-j-llc@outlook.com |
Business Manager |
Earlham |
Dallas |
Iowa |
Tim Hudson |
Kevin Gomez |
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 |
230 |
2020-08-13 16:59 |
Anonymous (not verified) |
174.217.21.76 |
Aaron Gilbert |
Proprietorship |
11864 W 125th St S, Runnells, IA 50237 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-13 |
Aaron Michael Gilbert |
gilbertinpc@msn.com |
Runnells |
Jasper |
Iowa |
Bob Coluzzi |
Mitch Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Michael Gilbert |
gilbertinpc@msn.com |
Same person |
Runnells |
Jasper |
Iowa |
Bob Coluzzi |
Mitch Coluzzi |
Signed |
146 |
2020-05-01 05:34 |
Anonymous (not verified) |
174.217.5.175 |
Five Nail Services |
Limited Liability Company |
32379 162nd Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-01 |
Ralph Chiodo |
rchiodo2@gmail.com |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ralph Chiodo |
rchiodo2@gmail.com |
Self |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
109 |
2020-04-03 12:42 |
Anonymous (not verified) |
174.219.131.25 |
Upright Construction |
Limited Liability Company |
2514 S norton ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-03 |
Maurice Williams |
uprightway@mail.com |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maurice Williams |
uprightway@mail.com |
Owner |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
105 |
2020-03-27 12:15 |
Anonymous (not verified) |
174.219.134.4 |
Elijah Willier |
Proprietorship |
805 SE 15th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-27 |
Elijah Willier |
e.willier42798@gmail.com |
Grimes |
Polk |
IA |
Isaac Willier |
Isaiah Willier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elijah Willier |
e.willier42798@gmail.com |
Self/ sole proprietor |
Grimes |
Polk |
IA |
Isaac Willier |
Isaiah Willier |
Signed |
793 |
2021-12-14 14:16 |
Anonymous (not verified) |
174.22.96.99 |
Dubuque County Energy District |
Limited Liability Company |
700 Locust Street, #195 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-10 |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Dubuque |
Dubuque |
IA |
Diane Freiburger, Mother |
Michael Freiburger, Father |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Contracted Vendor for the Dubuque County Energy District |
Dubuque |
Dubuque |
IA |
Diane Freiburger |
Michael Freiburger |
Signed |
1432 |
2023-01-25 16:52 |
Anonymous (not verified) |
174.228.33.48 |
Thermal Tight Insulators |
Proprietorship |
1331 Linden Road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-25 |
Shawn Carter |
steelershawn@gmail.com |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Carter |
steelershawn@gmail.com |
Self |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
1425 |
2023-01-18 15:20 |
Anonymous (not verified) |
174.228.35.74 |
Great-Dain Htg/Ac & Plumbing |
Proprietorship |
1616 Maple Rd Harlan, Iowa 51537 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-18 |
Richard Presly Nee |
great-dain@hotmail.com |
Harlan |
Shelby |
IA |
Theresa Clark |
Jesse Nee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Presley Nee |
great-dain@hotmail.com |
Self |
Harlan |
Shelby |
IA |
Theresa Clark |
Jesse Nee |
Signed |
1105 |
2022-05-16 13:40 |
Anonymous (not verified) |
174.235.192.160 |
Travis Montgomery Trucking LLC |
Limited Liability Company |
701 N 4th street Plainview Ne 68769 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Travis Montgomery |
travismontgomery76@gmail.com |
Plainview |
Pierce |
Nebraska |
Tim Woslager |
Trent Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Montgomery Trucking LLC |
travismotgomery76@gmail.com |
Owner |
Plainview |
Pierce |
Nebraska |
Trent Montgomery |
Tim woslager |
Signed |
1106 |
2022-05-16 13:40 |
Anonymous (not verified) |
174.235.192.160 |
Travis Montgomery Trucking LLC |
Limited Liability Company |
701 N 4th street Plainview Ne 68769 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Travis Montgomery |
travismontgomery76@gmail.com |
Plainview |
Pierce |
Nebraska |
Tim Woslager |
Trent Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Montgomery Trucking LLC |
travismotgomery76@gmail.com |
Owner |
Plainview |
Pierce |
Nebraska |
Trent Montgomery |
Tim woslager |
Signed |
1149 |
2022-06-09 17:43 |
Anonymous (not verified) |
174.235.192.238 |
Bryan Linares |
Limited Liability Company |
630 Hawthorne Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-09 |
Bryan Linares |
bryan.linares7798@gmail.com |
Crete |
Saline |
Nebraska |
Bryan Linares |
Chris Linares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Linares |
chris5linares1995@gmail.com |
Brother |
Crete |
Saline |
Nebraska |
Bryan Linares |
Chris Linares |
Signed |
1159 |
2022-06-17 10:58 |
Anonymous (not verified) |
174.235.208.232 |
Vertex Construction Services |
Limited Liability Company |
1620 E Diehl Ave, Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-17 |
William Dombrowski |
wdombrowski629@gmail.com |
Des moines |
Polk |
Iowa |
Clark Newbury |
Lisa Rodriguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Dombrowski |
wdombrowski629@gmail.com |
Owmer |
Des moines |
Polk |
Iowa |
Clark Newbury |
Lisa Rodriguez |
Signed |
1417 |
2023-01-11 08:55 |
Anonymous (not verified) |
174.235.209.245 |
Standard Insulation Company, LLC |
Limited Liability Company |
1066 Prairieview Ave., Van Meter, IA 50261 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-11 |
Mitchell Simonson |
standard.insulation@outlook.com |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Simonson |
standard.insulation@outlook.com |
Owner |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
1311 |
2022-09-15 16:49 |
Anonymous (not verified) |
174.235.213.195 |
JJ Jones contracting |
Limited Liability Company |
2413 Valley High Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-15 |
Justin Jones |
jjjonescontractingllc@gmail.com |
Cedar Falls |
Black Hawk |
IA |
Dahoni Jones |
Jerold Cemrick Jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Jones |
jjjonescontractingll@gmail.com |
Self |
Cedar Falls |
Black Hawk |
IA |
Dahoni Jones |
Jerold Cemrick Jones |
Signed |
1342 |
2022-10-25 09:02 |
Anonymous (not verified) |
174.240.251.79 |
Mahieu excavation |
Proprietorship |
6140 n Lincoln ave Davenport iowa 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-25 |
Joshua j Mahieu |
ridinmytrain2@gmail.com |
Davenport |
Scott |
Iowa |
Mike Leon |
Joseph Koranda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua j Mahieu |
ridinmytrain2@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Mike Leon |
Joseph Koranda |
Signed |
662 |
2021-10-01 16:05 |
Anonymous (not verified) |
174.242.224.18 |
Troy bryan |
Limited Liability Company |
2800 68th st urbandale Iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-01 |
Troy bryan |
tbryan0015@gmail.com |
Urbandale |
Polk |
Iowa |
Brenna painter |
Marc bryan |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Troy bryan |
tbryan0015@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Brenna painter |
Marc bryan |
Signed |
1225 |
2022-07-23 18:01 |
Anonymous (not verified) |
174.242.224.34 |
Ottumwa mow & snow llc |
Limited Liability Company |
11443 Bladensburg Rd Ottumwa IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-23 |
JoAnn laBella |
joannlabella@gmail.com |
Ottumwa |
Wapello |
IA |
Doug Knott |
Katy Knott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RJ Hallman |
rjhallman@fedins.com |
Insurance |
Owatonna |
Steele |
MN |
Katy knott |
Doug knott |
Signed |
1226 |
2022-07-23 18:02 |
Anonymous (not verified) |
174.242.224.34 |
Ottumwa mow & snow llc |
Limited Liability Company |
11443 Bladensburg Rd Ottumwa IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-23 |
JoAnn laBella |
joannlabella@gmail.com |
Ottumwa |
Wapello |
IA |
Doug Knott |
Katy Knott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RJ Hallman |
rjhallman@fedins.com |
Insurance |
Owatonna |
Steele |
MN |
Katy knott |
Doug knott |
Signed |
937 |
2022-02-25 11:55 |
Anonymous (not verified) |
174.242.226.43 |
K3 Recycling |
Limited Liability Company |
510 West 2nd Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-25 |
Justin Kappelman |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Kappelman |
justin@kappelmanappliance.com |
Same |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
1192 |
2022-07-07 21:15 |
Anonymous (not verified) |
174.242.226.74 |
Quelland Flooring |
Limited Liability Company |
P.O. Box 5, Van Meter, IA, 50261 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-07 |
Jared Tyler Quelland |
Jquelland@gmail.com |
Van Meter |
IA |
United States |
Denise Walters |
Madison Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Tyler Quelland |
Jquelland@gmail.com |
Self |
Van Meter |
IA |
United States |
Denise Walters |
Madison Mileer |
Signed |
664 |
2021-10-05 15:01 |
Anonymous (not verified) |
174.242.226.8 |
New Face Renovations |
Limited Liability Company |
3563 Richland Circle Van Meter, 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. |
2021-10-05 |
Darin Benjamin Davis |
newfacereno@gmail.com |
Van Meter |
Dallas |
Iowa |
Ryan Young |
Betsy Davis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Renda Building |
megemo@commdatalink.com |
Installer |
Grimes |
Polk |
Iowa |
Ryan Young |
Betsy Davis |
Signed |
184 |
2020-06-12 10:38 |
Anonymous (not verified) |
174.243.112.246 |
brian kass |
Proprietorship |
15064 kass road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
brian kass |
kass5kass@hotmail.com |
dubuque |
Iowa |
Iowa |
kelly kass |
jenny McIntyre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
brian kass |
kass5kass@hotmail.com |
self |
dubuque |
Iowa |
iowa |
Kelly Kass |
Jenny McIntyre |
Signed |
94 |
2020-03-18 13:18 |
Anonymous (not verified) |
174.243.114.80 |
Sogard Excavating |
Limited Liability Company |
2374 380th St, Jewell, IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
Jon A Sogard |
jsogard22@gmail.com |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sogard Excavating LLC |
jsogard22@gmail.com |
owner |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
296 |
2020-10-29 09:39 |
Anonymous (not verified) |
174.243.81.9 |
Alex Vanderbeek |
Proprietorship |
85 NE Grace Wood Drive, Waukee, Iowa 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. |
2020-10-29 |
Alex Vanderbeek |
Vanderbeek17151@gmail.com |
Waukee |
Dallas |
Iowa |
Joe Simpson |
James Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex Vanderbeek |
Vanderbeek17151@gmail.com |
self |
WAUKEE |
IA |
United States |
Joe Simpson |
James Nelson |
Signed |
341 |
2020-12-23 08:52 |
Anonymous (not verified) |
174.243.82.219 |
Jason D Struchen |
Proprietorship |
1778 210th St Webster City, IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-23 |
Jason David Struchen |
steruchen75@gmail.com |
Webster City |
Hamilton |
Iowa |
NA |
NA |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason D Struchen |
struchen75@gmail.com |
Same |
Webster City |
Hamilton |
Iowa |
NA |
NA |
Signed |
278 |
2020-10-09 11:25 |
Anonymous (not verified) |
174.243.82.229 |
ServTwelve7 Consulting, LLC |
Limited Liability Company |
1903 Elmhurst Avenue Humboldt, IA 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-09 |
Sonya Satern |
Sonya.satern@ServTwelve7.com |
Humboldt |
Humboldt |
Iowa |
Cindy Vik |
Jill Westre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sonya Satern |
Sonya.Satern@ServTwelve7.com |
self |
Humboldt |
Humboldt |
Iowa |
Cindy Vik |
Jill Westre |
Signed |
259 |
2020-09-16 15:44 |
Anonymous (not verified) |
174.243.82.6 |
Freedom Maintenance Services LLC |
Limited Liability Company |
1633 2nd 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. |
2020-09-16 |
Cole Keith McDonald |
cole.freedomservices@outlook.com |
Boone |
Boone |
IA |
Troy Thomas Graen |
Kurtis Joseph Wendl |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cole Keith McDonald |
cole.freedomservices@outlook.com |
Me |
Boone |
Boone |
IA |
Troy Thomas Graen |
Kurtis Joseph Wendl |
Signed |
748 |
2021-11-15 13:01 |
Anonymous (not verified) |
174.243.83.168 |
NC contracting |
Limited Liability Company |
2212 Oakwood Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-15 |
Nicholas Cheney |
444nicholas@gmail.com |
Ames |
Iowa |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Cheney |
444nicholas@gmail.com |
Self |
Ames |
Story |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
270 |
2020-09-25 10:14 |
Anonymous (not verified) |
174.243.97.206 |
J Watts Electric |
Limited Liability Company |
615 E 2nd St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-25 |
Jason Watts |
jason.watts@jwattselectric.com |
Webster City |
Hamilton |
Iowa |
Eli Ochoa |
Cody Ewing |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Watts |
jason.watts@jwattselectric.com |
Self |
Webster City |
Hamilton |
Iowa |
Eli Ochoa |
Cody Ewing |
Signed |
595 |
2021-08-03 13:53 |
Anonymous (not verified) |
174.248.224.252 |
Joseph r cunningham dba freedom field services |
Proprietorship |
6285 n 67th ave w Baxter iowa 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-03 |
Joseph r Cunningham jr. |
joecunningham1966@protonmail.com |
Baxter |
Jasper |
Iowa |
Chelsey Cunningham |
Chris Cort |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph r cunningham jr |
joecunningham1966@protonmail.com |
Me |
Baxter |
Jasper |
Iowa |
Chelsey cunningham |
Chris cort |
Signed |
103 |
2020-03-25 11:48 |
Anonymous (not verified) |
174.250.52.2 |
ReFormin' Homes |
Proprietorship |
7740 NW 16th Street, Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-25 |
Martin Samuel Ledy |
reforminhomes@gmail.com |
Ankeny |
Iowa |
United States |
Timothy Allen Raynard |
Nicholas Paul Curtis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Samuel Ledy |
reforminhomes@gmail.com |
Same Person |
Ankeny |
Iowa |
United States |
Timothy Allen Raynard |
Nicholas Paul Curtis |
Signed |
543 |
2021-06-16 12:49 |
Anonymous (not verified) |
174.250.64.145 |
McCulloch Construction LLC |
Limited Liability Company |
2590 SE 68TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-01 |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
Owner |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
274 |
2020-10-06 13:18 |
Anonymous (not verified) |
174.250.65.147 |
Ddp construction |
Proprietorship |
1923 63rd st. 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. |
2020-10-06 |
Dustin a perry |
perrythedustin@gmail.com |
Urbandale |
Polk |
Iowa |
Luke jackson |
Loud jackson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin perry |
perrythedustin@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Luke jackson |
Loyd jackson |
Signed |
624 |
2021-08-30 15:53 |
Anonymous (not verified) |
174.253.66.113 |
Leaf Home Solutions LLC |
Limited Liability Company |
1595 Georgetown Rd. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-30 |
Chad York |
Cyork027@gmail.com |
Davenport |
Scott |
Iowa |
Chad York |
Adam Coleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Coleman |
ARColeman@leafhome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Chad York |
Adam Coleman |
Signed |
1251 |
2022-08-11 09:11 |
Anonymous (not verified) |
174.255.1.226 |
Two Crew Remodeling and Maintenance |
Limited Liability Partnership |
11 C Ave Newhall, Iowa, 52315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-11 |
Trenten John Schafer |
Twocrewremodeling@gmail.com |
Newhall |
Benton |
Iowa |
Joeseph Allen Alger |
Glenn Mitchel Kieler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan McArtor |
Mcartorjordan@gmail.com |
Part owner |
cedar rapids |
CEDAR RAPIDS, IA (Inside) LINN |
Iowa |
Joeseph Allen Alger |
Glenn Mitchel Kieler |
Signed |
1244 |
2022-08-08 09:28 |
Anonymous (not verified) |
174.255.1.240 |
Jose Rivera |
Proprietorship |
6100 w lincoln way lot 25 Ames lA 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-08 |
Jose Rivera |
josechepe91@icloud.com |
Ames |
Boone |
lowa |
Jose Rivera |
Jose Rivera |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tim |
Tim@thefortress.net |
Friends |
Ames |
Boone |
Iowa |
Eliazar Martinez |
Sabino Díaz |
Signed |
1245 |
2022-08-08 09:28 |
Anonymous (not verified) |
174.255.1.240 |
Jose Rivera |
Proprietorship |
6100 w lincoln way lot 25 Ames lA 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-08 |
Jose Rivera |
josechepe91@icloud.com |
Ames |
Boone |
lowa |
Jose Rivera |
Jose Rivera |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tim |
Tim@thefortress.net |
Friends |
Ames |
Boone |
Iowa |
Eliazar Martinez |
Sabino Díaz |
Signed |
1002 |
2022-03-23 13:04 |
Anonymous (not verified) |
174.255.6.78 |
Gonzalez Contractors LLC. |
Limited Liability Company |
240 NE 41st St unit 203 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Elmer Gonzalez |
gonzalez922014@icloud.com |
Ankeny |
Polk |
IA |
Kassandra Gonzalez |
Jesus Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elmer Gonzalez |
gonzalez922014@icloud.com |
Owner |
Ankeny |
Polk |
IA |
Kassandra Gonzalez |
Jesus Gonzalez |
Signed |
1194 |
2022-07-08 13:12 |
Anonymous (not verified) |
174.45.15.103 |
307 Safety LLC |
Limited Liability Company |
9 Trinidad CT Gillette, WY 82716 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Owner |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
4 |
2019-11-12 09:06 |
Anonymous (not verified) |
174.71.54.19 |
M AND J LLC |
Limited Liability Company |
44100 STATE HIGHWAY 37 Dunlap, IA 51529 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-12 |
Mark Nichols |
mknichols2003@yahoo.com |
DUNLAP |
Monona |
IA |
Damon Nichols |
Bob Hall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Nichols |
mknichols2003@yahoo.com |
Partner |
Dunlap |
Monona |
IA |
Damon Nichols |
Bob Hall |
Signed |
5 |
2019-11-12 09:57 |
Anonymous (not verified) |
174.71.54.19 |
M AND J LLC |
Limited Liability Company |
44100 STATE HIGHWAY 37 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-12 |
M AND J, LLC |
mknichols2003@yahoo.com |
DUNLAP |
MONONA |
IA |
Damon Nichols |
Bob Hall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JAMES MUMM |
plipichok@yahoo.com |
Partner |
DUNLAP |
MONONA |
IA |
DAMON NICHOLS |
BOB HALL |
Signed |
910 |
2022-02-10 15:46 |
Anonymous (not verified) |
184.100.98.101 |
Carich properties |
Proprietorship |
6842 Fawn Rd. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-10 |
Chris Richard |
ticketbarandgrill@gmail.com |
Platteville |
Grant |
Wisconsin |
Allison Richard |
Melodee Richard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Richard |
ticketbarandgrill@gmail.com |
Owner |
Platteville |
Grant |
Wisconsin |
Allison Richard |
Melodee Richard |
Signed |
518 |
2021-05-12 19:22 |
Anonymous (not verified) |
184.105.50.148 |
Angela Smith and Christopher Smith |
Proprietorship |
2321 130th Street Belmond, IA 50421 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-08 |
Christopher Lynn Smith |
1angismith@gmail.com |
Belmond |
Wright |
Iowa |
Betty Warrington |
Nicholas Mehmen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Angela Kay Smith |
1angismith@gmail.com |
Wife |
Belmond |
Wright |
Iowa |
Betty Warrington |
Nicholas Mehmen |
Signed |
568 |
2021-07-09 09:26 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
P.O. Box 561 Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-05-21 |
Jason Snow |
k.kooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
k.kooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
570 |
2021-07-09 16:42 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
P.O. Box 561 Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-05-21 |
Jason Snow |
kkooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
kkooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
593 |
2021-08-03 12:29 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
PO Box 561, Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-05-21 |
Jason Snow |
k.kooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
k.kooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
501 |
2021-04-29 15:47 |
Anonymous (not verified) |
184.179.6.93 |
Rodney Bohannon |
Proprietorship |
5221 Crogans Way Rd, Council Bluffs IA 51501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-29 |
Rodney Bohannon |
bohannonrod@gmail.com |
Council Bluffs |
POTTAWATTAMIE |
iowa |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodney Bohannon |
bohannonrod@gmail.com |
Owner |
Council Bluffs |
POTTAWATTAMIE |
IA |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
377 |
2021-01-26 13:31 |
Anonymous (not verified) |
184.63.6.1 |
Matt Reynolds |
Proprietorship |
684 Cedar Valley Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-26 |
Matt Reynolds |
matt.reynolds0891@gmail.com |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Reynolds |
matt.reynolds0891@gmail.com |
Proprietorship |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
578 |
2021-07-16 15:26 |
Anonymous (not verified) |
184.80.177.137 |
Scotty's Appliance & TV, LLC |
Limited Liability Company |
529 5th St NW - Dyersville, IA 52040 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-16 |
Sandra Krogman |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
596 |
2021-08-04 10:48 |
Anonymous (not verified) |
184.80.177.137 |
Down Home Decor Inc |
Proprietorship |
1021 2nd Ave SE Ste 200 Dyersville, IA 52040 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-04 |
Steve Knipper |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
757 |
2021-11-19 15:11 |
Anonymous (not verified) |
184.80.177.137 |
Upper Room, LLC |
Limited Liability Company |
1314 9th St SE -Dyersville, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-19 |
DeAnne M McCarraher |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville, IA |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
758 |
2021-11-19 15:12 |
Anonymous (not verified) |
184.80.177.137 |
Upper Room, LLC |
Limited Liability Company |
1314 9th St SE - Dyersville, IA 52040 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-19 |
Keith McCarraher |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
1239 |
2022-08-02 10:53 |
Anonymous (not verified) |
184.80.177.137 |
Jamie Ingle, DBA Jamie's Little Sunflowers |
Proprietorship |
7155 Columbus St - New Vienna, IA 52065 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Jamie Ingle |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
1316 |
2022-09-21 14:49 |
Anonymous (not verified) |
184.81.198.17 |
Ellen Faye Stevenson |
Proprietorship |
201 Stephans st. Tiffin, Iowa 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. |
2022-09-21 |
Ellen Faye Stevenson |
nelle@southslope.net |
Tiffin |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ellen Faye Stevenson |
nelle@southslope.net |
myself |
Tiffin |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
1317 |
2022-09-21 15:04 |
Anonymous (not verified) |
184.81.198.17 |
Mark Jagnow |
Proprietorship |
2174 Rohret Rd SW Oxford IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-21 |
Mark Allen Jagnow |
Mark@Jagnow.com |
Oxford |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Allen Jagnow |
Mark@jagnow.com |
self |
Oxford |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
818 |
2022-01-02 11:34 |
Anonymous (not verified) |
184.94.130.66 |
dylan nelson trucking llc |
Limited Liability Company |
2011 465th street hanley falls mn 56245 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
dylan nelson |
dylancvi@gmail.com |
hanley falls mn |
yellow medicine |
mn |
derek verhelst |
mike fales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
dylan nelson |
dylancvi@gmail.com |
owner |
hanley falls mn |
yellow medicine |
mn |
derek verhelst |
mike fales |
Signed |
819 |
2022-01-02 11:39 |
Anonymous (not verified) |
184.94.130.66 |
derek verhelst trucking inc |
Proprietorship |
1579 270th avenue canby mn 56220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
derek verhelst |
derekvtinc@gmail.com |
canby |
yellow medicine |
mn |
lois verhelst |
dylan nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
derek verhelst |
derekvtinc@gmail.com |
owner |
canby |
yellow medicine |
mn |
lois verhelst |
dylan nelson |
Signed |
1433 |
2023-01-27 13:24 |
Anonymous (not verified) |
184.97.152.214 |
Rwdcarpet |
Proprietorship |
4927 cedarbrook drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-27 |
Robert Wayne Durand iii |
rwdcarpet24@gmail.com |
Council bluffs |
Pottawattamie |
Iowa |
Kitty whissinand |
Kelley durand |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Wayne Durand iii |
rwdcarpet24@gmail.com |
Self |
Council bluffs |
Pottawattamie |
Iowa |
Kitty whissinand |
Kelley Durand |
Signed |
534 |
2021-06-04 12:47 |
Anonymous (not verified) |
192.119.129.187 |
KMA Communications, LLC |
Limited Liability Company |
435 croston rd. Stockport, OH 43787 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-04 |
Matthew Razen Alsup |
malsupbrgi@gmail.com |
Stockport |
Morgan |
Ohio |
Stephen Alsup |
Nancy Alsup |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Razen Alsup |
malsupbrgi@gmail.com |
Same person |
Stockport |
Morgan |
Ohio |
Stephen Alsup |
Nancy Alsup |
Signed |
535 |
2021-06-04 13:16 |
Anonymous (not verified) |
192.119.129.187 |
KMA Communications, LLC |
Limited Liability Company |
435 croston rd. Stockport, OH 43787 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-04 |
Kenneth Stephen Alsup |
kenneth.alsup@yahoo.com |
Walker |
Wood |
West Virginia |
Stephen Alsup |
Nancy Alsup |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kenneth Stephen Alsup |
kenneth.alsup@yahoo.com |
Same Person |
Walker |
Wood |
West Virginia |
Stephen Alsup |
Nancy Alsup |
Signed |
1045 |
2022-04-13 09:55 |
Anonymous (not verified) |
192.119.237.126 |
BARGAIN HOUSE |
Proprietorship |
11 S FREDERICK AVE, OELWEIN, IA 50662 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-13 |
RICHARD M. BECKER |
SHELBY@CIOIA.COM |
HAZLETON |
BUCHANAN |
IOWA |
SHELBY S. WILLIAMS |
BOBBIE J. BERGAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICHARD M. BECKER |
SHELBY@CIOIA.COM |
OWNER |
OELWEIN |
FAYETTE |
IOWA |
SHELBY S. WILLIAMS |
BOBBIE J. BERGAN |
Signed |
619 |
2021-08-25 14:31 |
Anonymous (not verified) |
192.154.15.2 |
MAV Restorations LLC |
Limited Liability Company |
5461 Meadow Ct, Asbury, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-25 |
Matthew Vaske |
mlvaske@gmail.com |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Vaske |
mlvaske@gmail.com |
Self |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
283 |
2020-10-21 09:19 |
Anonymous (not verified) |
192.16.108.199 |
Blazin Homes |
Proprietorship |
2306 Hill St 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. |
2020-10-21 |
Chad David Blasey |
chadblasey@yahoo.com |
Denison |
Crawford |
Iowa |
Amy Hansen |
Todd Stadtlander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad David Blasey |
chadblasey@yahoo.com |
Owner |
Dension |
Crawford |
Iowa |
Amy Hansen |
Todd Stadtlander |
Signed |
776 |
2021-12-03 10:26 |
Anonymous (not verified) |
192.230.128.72 |
Richard Makohoniuk |
Proprietorship |
785 SE Walnut Ridge Dr 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. |
2021-12-03 |
Richard Makohoniuk |
111@mchsi.com |
Waukee |
Dallas |
Iowa |
Tara Makohoniuk |
Richard Makohoniuk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Makohoniuk |
111@mchsi.com |
Self |
Waukee |
Dallas |
IA |
Tara Makohoniuk |
Richard Makohoniuk |
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 |
382 |
2021-02-02 13:19 |
Anonymous (not verified) |
192.30.185.142 |
Double D Weatherization |
Proprietorship |
2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-02 |
Dale Gernhart |
lakehome@longlines.com |
Sergeant Bluff |
Woodbury |
IA |
Nate Blaeser |
Jenni Ebner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dale Gerhart |
lakehome@longlines.com |
Self |
Sergeant Bluff |
Woodbury |
IA |
Nate Blaeser |
Jennie Ebner |
Signed |
386 |
2021-02-08 12:10 |
Anonymous (not verified) |
192.30.185.142 |
CS Iron Design |
Proprietorship |
311 Powells Addition, Crescent, IA 51526 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-08 |
Christopher Stoffel |
ctstoffel@gmail.com |
Crescent |
Pottawattamie |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Stoffel |
ctstoffel@gmail.com |
Owner |
Crescent |
Pottawattamie |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
387 |
2021-02-08 14:26 |
Anonymous (not verified) |
192.30.185.142 |
Go 2 Girls |
Proprietorship |
104 Doral Lane, Dakota Dunes, SD 57049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-08 |
Tawnya Oneill |
tawny5881@gmail.com |
Dakota Dunes |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tawnya Oneill |
tawny5881@gmail.com |
Owner |
Dakota Dunes |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
392 |
2021-02-11 10:07 |
Anonymous (not verified) |
192.30.185.142 |
Neiman Electric |
Proprietorship |
301 West Creek Dr, Lawton, IA 51030 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
John Neiman, Jr |
neiman009@yahoo.com |
Lawton |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Neiman, Jr. |
neiman009@yahoo.com |
Owner |
Lawton |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
399 |
2021-02-15 14:44 |
Anonymous (not verified) |
192.30.185.142 |
Poss Concrete |
Proprietorship |
3106 Dodge Ave, Sioux City, IA 51106 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-15 |
Corey Poss |
coreyposs1@gmail.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Poss |
coreyposs1@gmail.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
400 |
2021-02-15 14:44 |
Anonymous (not verified) |
192.30.185.142 |
Certified Radon Mitigation |
Proprietorship |
4304 Garretson Ave, Sioux City, IA 51106 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-15 |
Erik Poss |
rn222@outlook.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erik Poss |
rn222@outlook.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
403 |
2021-02-16 11:20 |
Anonymous (not verified) |
192.30.185.142 |
Rodrigo Ochoa |
Proprietorship |
3310 5th St, Sioux City, IA 51105 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-16 |
Rodrigo Ochoa |
jesusochoa1976@icloud.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Jenni Ebner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodrigo Ochoa |
jesusochoa1976@icloud.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Jenni Ebner |
Signed |
430 |
2021-03-10 13:01 |
Anonymous (not verified) |
192.30.185.142 |
Trey LaGois Construction |
Proprietorship |
132 W Cedar St, Hinton, IA 51024 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
Trey LaGois |
treylagois2015@gmail.com |
Hinton |
Plymouth |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trey LaGois |
treylagois2015@gmail.com |
Owner |
Hinton |
Plymouth |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
435 |
2021-03-15 15:09 |
Anonymous (not verified) |
192.30.185.142 |
Marx Construction |
Proprietorship |
33044 484th Ave, Jefferson, SD 57038 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-15 |
Tony Marx |
tmarx416@hotmail.com |
Jefferson |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tony Marx |
tmarx416@hotmail.com |
Owner |
Jefferson |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
453 |
2021-03-26 08:27 |
Anonymous (not verified) |
192.30.185.142 |
DYAD LLC |
Partnership |
2308 Summit St, Sioux City, IA 51104 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-26 |
Andrew Glisar |
john@kellyconstruction.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Jenni Ebner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Glisar |
john@kellyconstruction.com |
Owner/Partner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Jenni Ebner |
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 |
507 |
2021-05-10 10:20 |
Anonymous (not verified) |
192.30.186.37 |
Stowe's Drywall |
Proprietorship |
PO Box 712, Ponca, NE 68776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Danny Stowe |
deb.nana.stowe@gmail.com |
Ponca |
Dixon |
NE |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Danny Stowe |
deb.nana.stowe@gmail.com |
Owner |
Ponca |
Dixon |
NE |
Katie Jenks |
Virginia Anderson |
Signed |
770 |
2021-11-22 18:17 |
Anonymous (not verified) |
192.82.97.13 |
Paul Wire |
Proprietorship |
1005 25th Street SW, 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. |
2021-11-22 |
Paul Wire |
gizzmochee@gmail.com |
Spencer |
Clay |
IA |
Lori Wire |
Abigail Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Wire |
gizzmochee@gmail.com |
Self |
Spencer |
Clay |
IA |
Lori Wire |
Abigail Miles |
Signed |
981 |
2022-03-16 13:51 |
Anonymous (not verified) |
192.95.125.117 |
W.S. Amsden |
Proprietorship |
405 E 4th Street Vinton IA 52349 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-16 |
William Shane Amsden |
nmckenna@fsb-vinton.com |
Vinton |
Benton |
Iowa |
Nichole M McKenna |
Teresa Wehage |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Shane Amsden |
nmckenna@fsb-vinton.com |
Self |
Vinton |
Benton |
Iowa |
Nichole M McKenna |
Terie Wehage |
Signed |
943 |
2022-03-03 13:49 |
Anonymous (not verified) |
192.95.125.191 |
B & R Enterprises LLC |
Limited Liability Company |
2850 73rd St, Newhall, IA 52315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2022-02-17 |
Ronald Jarrett |
ashlyn@3riversins.net |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ronald Jarrett |
brsirenguys@gmail.com |
Member of LLC |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
944 |
2022-03-03 13:54 |
Anonymous (not verified) |
192.95.125.191 |
B&R Enterprises LLC |
Limited Liability Company |
2850 73rd St., Newhall, IA 52315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2022-02-17 |
Bradley Rick |
ashlyn@3riversins.net |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ronald Jarrett |
brsirenguys@gmail.com |
LLC Member |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
665 |
2021-10-06 09:22 |
Anonymous (not verified) |
192.96.173.171 |
Michael Childers |
Proprietorship |
21 N.6th street savanna Illinois |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-06 |
Michael Childers |
peddler73@hotmail.com |
Savanna |
Carroll |
Illinois |
Brandy arnold |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas city |
Clay |
Mo |
Jordan nisiewicz |
Brandy arnold |
Signed |
1372 |
2022-11-14 20:36 |
Anonymous (not verified) |
198.14.213.147 |
Accurate Grading, LLC |
Limited Liability Company |
1417 290th St Macksburg, IA 50155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-14 |
Dustin A McVay |
dustin0980@gmail.com |
Macksburg |
IA |
United States |
Dustin A McVay |
Angela D McVay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin A McVay |
dustin0980@gmail.com |
Owner |
Macksburg |
United States |
Iowa |
Dustin A McVay |
Angela D McVay |
Signed |
764 |
2021-11-22 15:33 |
Anonymous (not verified) |
198.14.219.227 |
Central Iowa Painting and Contracting LLC |
Limited Liability Company |
408 Freel Drive, Ste. 101, Ames, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Matthew Paul Klucas |
mklucas50@gmail.com |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Klucas |
mklucas50@gmail.com |
Owner of Buisness |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
1213 |
2022-07-19 14:00 |
Anonymous (not verified) |
198.14.220.143 |
VLG Build & Remodle LLC |
Limited Liability Partnership |
45547 State HWY 14 Chariton, IA 50049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-19 |
Vladimir Golosinskiy |
VLGCONSTRUCTION@YAHOO.COM |
Chariton |
IA |
United States |
Vladimir Golosinskiy |
Vladimir Golosinskiy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LILIA GOLOSINSKIY |
VLGCONSTRUCTION@YAHOO.COM |
Wife |
CHARITON |
Iowa |
United States |
LILIA GOLOSINSKIY |
LILIA GOLOSINSKIY |
Signed |
1290 |
2022-09-01 15:29 |
Anonymous (not verified) |
198.14.221.176 |
DR. WAYNE HAIDSIAK ii and Dr. Junior Hensley DBA Tri County Veterinary Service |
Partnership |
101 170TH ST CLEARFIELD IA 50840 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-01 |
Dr. Wayne Haidsiak II |
insurance@ringgoldins.com |
Lenox |
Taylor |
IA |
Amy Ford |
Deb Davenport |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dr. J.D. Hensley |
insurance@ringgoldins.com |
Partner |
Cleafield |
Taylor |
IA |
Amy Ford |
Deb Davenport |
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 |
69 |
2020-02-19 15:58 |
Anonymous (not verified) |
198.14.241.59 |
MORENOS C ROOFING LLC |
Limited Liability Company |
2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
OWNER |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
896 |
2022-02-04 11:58 |
Anonymous (not verified) |
198.167.180.146 |
Northtowne Market Lot 7, LLC |
Limited Liability Company |
1005 Blairs Ferry Road NE, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-04 |
Benjamin Wickum |
bwickum@collinscu.org |
CEDAR RAPIDS |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benjamin Wickum |
bwickum@collinscu.org |
Manager |
Cedar Rapids |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
57 |
2020-02-10 15:33 |
Anonymous (not verified) |
198.167.182.164 |
AllEnhancements LLC |
Limited Liability Company |
1122 Woodland Ln, LeClaire, IA 52753 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Brett Allen |
allenhancementsllc@outlook.com |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brett Allen |
allenhancementsllc@outlook.com |
Managing Member |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
59 |
2020-02-11 11:34 |
Anonymous (not verified) |
198.167.182.164 |
Besch Electric LLC |
Limited Liability Company |
317 Sycamore St, Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-03 |
Daniel Besch |
beschd@hotmail.com |
Riverside |
Washington |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Besch |
beschd@hotmail.com |
Managing Member |
Riverside |
Washington |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
60 |
2020-02-12 10:10 |
Anonymous (not verified) |
198.167.182.164 |
Sara Torres |
Proprietorship |
419 Lilac St, 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. |
2020-02-11 |
Sara Torres |
skb_blue08@hotmail.com |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E. Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sara Torres |
skb_blue08@hotmail.com |
Owner |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
64 |
2020-02-18 10:02 |
Anonymous (not verified) |
198.167.182.164 |
Elite Electrical Service LLC |
Limited Liability Company |
2035 Lynncrest Dr, 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. |
2020-02-18 |
Sean Brogan |
brogan_sean@hotmail.com |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Brogan |
brogan_sean@hotmail.com |
Managing Member |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
67 |
2020-02-19 10:16 |
Anonymous (not verified) |
198.167.182.164 |
AWF579 LLC |
Limited Liability Company |
13 Lynden Dr NE, Iowa City, IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Managing Member |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
84 |
2020-02-28 15:30 |
Anonymous (not verified) |
198.167.182.164 |
Rid-A-Bird Inc. |
Limited Liability Company |
3116 Friendship St. Iowa City IA 52245 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-28 |
Keith Wilson |
kwilson@windowgenie.com |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Wilson |
kwilson@windowgenie.com |
Managing member |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
85 |
2020-03-09 08:17 |
Anonymous (not verified) |
198.167.182.164 |
Simply Anchored LLC dba Simply Mae's |
Limited Liability Company |
601 Broad St, Story City, IA 50248 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Jessi Kettenacker |
jessi@simplymaes.com |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jessi Kettenacker |
jessi@simplymaes.com |
Managing Member |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
86 |
2020-03-09 08:19 |
Anonymous (not verified) |
198.167.182.164 |
Simply Anchored LLC dba Simply Mae's |
Limited Liability Company |
601 Broad St, Story City, IA 50248 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Cande Coulter |
cande@simplymaes.com |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candy Coulter |
cande@simplymaes.com |
Managing Member |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
151 |
2020-05-07 15:57 |
Anonymous (not verified) |
198.167.182.164 |
Hawk-I Trucking LLC |
Limited Liability Company |
521 Greenfield 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. |
2020-05-06 |
Chad Lee Freeman |
ricenogle@southslope.net |
Tiffin |
Johnson |
IA |
Scott Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Lee Freeman |
ricenogle@southslope.net |
Managing Member |
Tiffin |
Johnson |
IA |
Scott Freeman |
Dyan Kriener |
Signed |
152 |
2020-05-11 15:56 |
Anonymous (not verified) |
198.167.182.164 |
Hawk-I Trucking LLC |
Limited Liability Company |
521 Greenfield 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. |
2020-05-11 |
Tyler Rogers |
tylerrogersinc@yahoo.com |
Iowa City |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Rogers |
tylerrogersinc@yahoo.com |
Member |
Iowa City |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |
438 |
2021-03-17 06:52 |
Anonymous (not verified) |
198.167.182.164 |
David L Ridnour |
Proprietorship |
1415 4th St, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-16 |
David L Ridnour |
dlridnour@gmail.com |
Perry |
Dallas |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David L Ridnour |
dlridnour@gmail.com |
Owner |
Perry |
Dallas |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
30 |
2020-01-07 08:34 |
Anonymous (not verified) |
199.10.5.7 |
Data Information Management LLC |
Limited Liability Company |
703 Bluff St Dubuque IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-07 |
Stephen M Schauff |
steve@caricomm.com |
Dubuque |
Iowa |
IA |
Janet L Schauff |
Morris P Schauff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher R Broessel |
chris@caricomm.com |
Partner |
Dubuque |
Iowa |
IA |
Janet L Schauff |
Morris P schauff |
Signed |
31 |
2020-01-07 08:37 |
Anonymous (not verified) |
199.10.5.7 |
Data Information Management LLC |
Limited Liability Company |
703 Bluff St Dubuque IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-07 |
Christopher R Broessel |
chris@caricomm.com |
Dubuque |
Dubuque |
IA |
Janet L Schauff |
Morris P Schauff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen M schauff |
steve@caricomm.com |
Partner |
Dubuque IA |
Dubuque |
Iowa |
Janet L schauff |
Morris P Schauff |
Signed |
491 |
2021-04-20 15:57 |
Anonymous (not verified) |
199.102.210.217 |
mjm,inc |
Proprietorship |
32345 200th st dallas centert ia 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-20 |
john paul wewrner |
johnpwerner17@gmail.com |
osage |
michell |
ia |
carolyn lee werner |
amanda lee johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
johnwerner |
johnpwerner17@gmail.com |
friend |
osage |
mithell |
ia |
carolyn lee werner |
amanda lee johnson |
Signed |
506 |
2021-05-10 09:29 |
Anonymous (not verified) |
199.102.211.129 |
Nathan J Hurst LLC DBA J&K Construction |
Limited Liability Company |
3598 Orchard Rd. Osage, IA 50461 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Nathan J Hurst |
jkconstructionjake@yahoo.com |
Osage |
Mitchell |
Iowa |
Breanna Fox |
Karl Herman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Breanna Fox |
jkconstructionjake@yahoo.com |
Office Manager |
Osage |
Mithell |
Iowa |
Nathan J Hurst |
Karl F Herman |
Signed |
32 |
2020-01-08 08:31 |
Anonymous (not verified) |
199.120.118.90 |
BOBCATS LLC |
Limited Liability Company |
1860 505TH ST LINN GROVE 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. |
2019-11-18 |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
OWNER |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
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 |
1039 |
2022-04-11 14:33 |
Anonymous (not verified) |
199.120.121.97 |
Panama Electric |
Proprietorship |
106 S Railway Panama IA 51562 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-11 |
Dan Wingert |
danwingert@fmctc.com |
Panama |
Shelby |
IA |
Laura Wingert |
Sylvan Kenkel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Wingert |
danwingert@fmctc.com |
Self |
Panama |
Shelby |
IA |
Laura Wingert |
Sylvan Kenkel |
Signed |
1413 |
2023-01-06 15:15 |
Anonymous (not verified) |
199.120.121.97 |
Jason Gaul |
Proprietorship |
1088 Ridge Lane Harlan, IA 51537 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-06 |
Jason Robert Gaul |
gauljasonr@gmail.com |
Harlan |
Shelby |
Iowa |
Haley Leinen |
Scott Leinen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Robert Gaul |
gauljasonr@gmail.com |
Self |
Harlan |
Shelby |
Iowa |
Haley Leinen |
Scott Leinen |
Signed |
413 |
2021-02-24 16:21 |
Anonymous (not verified) |
199.120.93.40 |
Nelson Tire Recycling LLC |
Limited Liability Company |
2270 Farley Rd Cascade Iowa 52033 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-02-24 |
Richard A Nelson |
nelsontirerecycling@gmail.com |
Cascade |
Dubugue |
Iowa |
Wendy Bergfeld |
Jan Elhinger |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Richard |
nelsontirerecycling@gmail.com |
Owner/officer |
Cascade |
Dubugue |
Iowa |
Wendy Bergfeld |
Jan Ehlinger |
Signed |
874 |
2022-01-30 19:13 |
Anonymous (not verified) |
199.168.106.132 |
Pete Wilcox Trenching |
Proprietorship |
714 Main Street Cedar Falls IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-29 |
Peter Wilcox |
kwilcox@cfu.net |
Cedar Falls |
Black Hawk |
Iowa |
Terri Strein |
Marlene Rasmussen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
The Accel Group LLC |
info@acceladvantage.com |
customer |
Cedar Falls |
Black Hawk |
IA |
Terri Strein |
Marlene Rasmussen |
Signed |
654 |
2021-09-24 15:08 |
Anonymous (not verified) |
199.247.64.87 |
Steve Porter DBA Precision Striping |
Proprietorship |
408 Embassy Ct. Sergeant Bluff, IA 51054 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-23 |
Steve Porter |
steve.porter2710@gmail.com |
Sergeant Bluff |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jana Reich |
JNeuzil@reichpainting.com |
Office Manager |
Sioux City |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
1092 |
2022-05-09 17:49 |
Anonymous (not verified) |
199.247.76.21 |
Mitchell Ellison |
Limited Liability Company |
906 Lakeshore Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-09 |
Mitchell Ellison |
Essential.ellison@gmail.com |
Lakeside |
Iowa |
United States |
Mitchell Ellison |
Mitchell Ellison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Ellison |
Essential.ellison@gmail.com |
Self |
Lakeside |
Iowa |
United States |
Mitchell Ellison |
Mitchell Ellison |
Signed |
915 |
2022-02-15 16:43 |
Anonymous (not verified) |
199.247.79.215 |
Dale B Wetherell Trucking |
Proprietorship |
5844 40th Ave., Alta, IA 51002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-15 |
Dale Wetherell |
barbw@sppinsurance.com |
Alta |
Iowa |
Iowa |
Barbara Wetherell |
Kelli Turnquist |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dale Wetherell |
barbw@sppinsurance.com |
Self |
Alta |
Buena Vista |
IA - Iowa |
Barb Wetherell |
Kelli Turnquist |
Signed |
1051 |
2022-04-14 17:56 |
Anonymous (not verified) |
199.59.236.46 |
Triple M Welding |
Proprietorship |
407 4th St Sw |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Owner |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
1098 |
2022-05-12 17:54 |
Anonymous (not verified) |
199.66.15.123 |
Timothy W Robinson |
Proprietorship |
302 N Kenwood blvd Indianola 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. |
2022-05-12 |
Timothy William Robinson |
williamswork18@gmail.com |
Indianola |
Warren |
Iowa |
Sarah Anne Robinson |
Andrew Gilbert Barber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy William Robinson |
williamswork18@gmail.com |
Sole proprietor |
Indianola |
Warren |
Iowa |
Sarah Anne Robinson |
Andrew Gilbert Barber |
Signed |
866 |
2022-01-27 19:15 |
Anonymous (not verified) |
199.66.15.25 |
Greg Cheno Services LLC |
Limited Liability Company |
203 N H St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Gregory Chenoweth |
gregcheno@gmail.com |
Indianola |
IA |
United States |
Rebecca Sue Abbott |
Gregory Blair Abbott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gregory J. Chenoweth |
gregcheno@gmail.com |
Same |
Indianola |
Warren |
Iowa |
Rebecca Sue Abbott |
Gregory Blair Abbott |
Signed |
481 |
2021-04-14 17:15 |
Anonymous (not verified) |
199.66.15.81 |
K3 Recycling |
Limited Liability Company |
601 W. 1st 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. |
2021-04-14 |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charlie Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Same person |
Indianola |
IA |
IA |
Kristy Kappelman |
Charlie Kappelman |
Signed |
305 |
2020-11-02 08:40 |
Anonymous (not verified) |
204.124.192.31 |
JPS Framing |
Proprietorship |
102 WALL AVE - DES MOINES IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-02 |
JACKELYN SANCHEZ |
JPSFRAMING629@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUAN SERRANO |
JPSFRAMING629@GMAIL.COM |
EMPLOYER |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
1321 |
2022-09-26 08:16 |
Anonymous (not verified) |
204.141.215.159 |
Leaf filter |
Limited Liability Company |
615 J Ave NE Cedar Rapids, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-26 |
Dustin Hansen |
dhansen0925@gmail.com |
Marion |
Linn |
Iowa |
Audrianna Cleveland |
Trevor Frondle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaf filter |
sewell@leafhome.com |
N/a |
Cedar rapids |
Linn |
Iowa |
N/a |
N/a |
Signed |
497 |
2021-04-27 09:25 |
Anonymous (not verified) |
204.153.176.147 |
SHANE HUCK |
Proprietorship |
1070 305TH STREET, NASHUA, IOWA 50658 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-27 |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
OWNER |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
55 |
2020-02-07 15:14 |
Anonymous (not verified) |
204.153.176.73 |
J*M Fuels, LLC |
Limited Liability Company |
600 W Bremer Avenue, Waverly IA 50677 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-07 |
Matt Johnson |
mattjohnson7555@gmail.com |
Jackson TWP |
Butler |
Iowa |
Ty Burke |
Lori Frerichs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tylor Burke |
tburke@acceladvantage.com |
Agent |
Waverly |
IA |
United States |
Tony Pollastrini |
Lori Frerichs |
Signed |
56 |
2020-02-07 15:17 |
Anonymous (not verified) |
204.153.176.73 |
J*M Fuels, LLC |
Limited Liability Company |
600 W Bremer Avenue, Waverly IA 50677 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-07 |
Jim Johnson |
mattjohnson7555@gmail.com |
Jackson TWP |
Butler |
Iowa |
Ty Burke |
Lori Frerichs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ty Burke |
tburke@acceladvantage.com |
Agent |
Waverly |
IA |
United States |
Tony Pollastrini |
Lori Frerichs |
Signed |
483 |
2021-04-16 10:47 |
Anonymous (not verified) |
204.155.61.217 |
Joseph Jones DBA Jones Sealcoating and Asphalt Repair |
Limited Liability Company |
1033 Hummingbird Cir |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-16 |
Joseph Jones |
iscrapcu@yahoo.com |
Waterloo |
Iowa |
Iowa |
Kyle Hildman |
Dan Sinnott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jospeh Jones |
iscrapcu@yahoo.com |
OWNER |
Waterloo |
Black Hawk |
IA |
Kyle Hildman |
Dan Sinnott |
Signed |
500 |
2021-04-29 13:09 |
Anonymous (not verified) |
204.155.61.217 |
JWJ Home Remodeling LLC |
Limited Liability Company |
16915 Weaver Lake Dr, Maple Grove MN 55311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-29 |
Jackson Janzen |
jacksonjanzen@hailmayday.com |
Maple Grove |
hennepin |
MN |
Ashley Kraft |
DocuSign |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jackson Janzen |
jacksonjanzen@hailmayday.com |
Owner |
Maple Grove |
Hennepin |
MN |
Ashley Kraft |
DocuSign |
Signed |
577 |
2021-07-16 13:45 |
Anonymous (not verified) |
204.155.61.217 |
Chris & Michele Burke dba Studio Dance |
Proprietorship |
3907 Center Point Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-07-16 |
Michele Burke |
michele@studiodanceia.com |
Marion |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Michele Burke |
michele@studiodanceia.com |
owner |
Marion |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
597 |
2021-08-05 13:38 |
Anonymous (not verified) |
204.155.61.217 |
Haag Consulting LLC |
Limited Liability Company |
8602 E Kael Circle, Mesa, AZ 85207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-05 |
Justin Haag |
haag.justin1@gmail.com |
Mesa |
unknown |
AZ |
DocuSign |
Ashley Kraft |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Haag |
haag.justin1@gmail.com |
Owner |
Mesa |
unknown |
AZ |
DocuSign |
Ashley Kraft |
Signed |
628 |
2021-09-01 09:39 |
Anonymous (not verified) |
204.155.61.217 |
Utzinger Epoxy & Concrete, LLC |
Limited Liability Company |
1595 Highway 1 Washington, Iowa 52353 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-01 |
Troy Utzinger |
tbutzinger99@kctc.net |
Washington |
Washington |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Utzinger |
tbutzinger99@kctc.net |
owner |
Washington |
Washington |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
629 |
2021-09-01 09:44 |
Anonymous (not verified) |
204.155.61.217 |
Thrapp Electric |
Proprietorship |
708 2nd Street Wellman, Iowa 52356 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-01 |
Jay Thrapp |
socketman5555@hotmail.com |
Wellman |
Washington |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Thrapp |
socketman5555@hotmail.com |
Owner |
Wellman |
Washington |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
637 |
2021-09-10 15:15 |
Anonymous (not verified) |
204.155.61.217 |
Duwa Waterproofing LLC |
Limited Liability Company |
1548 150th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
owner |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
859 |
2022-01-27 11:29 |
Anonymous (not verified) |
204.155.61.217 |
JD Drywall |
Proprietorship |
503 9th Street Kalona, Iowa 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
John Duwa |
johnduwa@outlook.com |
Kalona |
Washington |
Iowa |
Angela Stutzman |
Jeff Spenner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JD Drywall - John Duwa |
johnduwa@outlook.com |
owner |
Kalona |
Washington |
Iowa |
Angela Stutzman |
Jeff Spenner |
Signed |
892 |
2022-02-03 15:52 |
Anonymous (not verified) |
204.155.61.217 |
JD DRYWALL |
Proprietorship |
503 9th Street Kalona, Iowa 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-03 |
John Duwa |
johnduwa@outlook.com |
Kalona |
Washington |
Iowa |
Jeff Spenner |
Angela Stutzman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JD Drywall - John Duwa |
johnduwa@outlook.com |
owner |
Kalona |
Washington |
Iowa |
Jeff Spenner |
Angela Stutzman |
Signed |
83 |
2020-02-28 12:55 |
Anonymous (not verified) |
204.16.58.27 |
Baltes Trucking LLC |
Limited Liability Company |
203 N Gilmore Ave New Hampton IA 50659 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-28 |
Clinton Lee Baltes |
clintbaltes@gmail.com |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clinton Lee Baltes |
clintbaltes@outlook.com |
Owner |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
1057 |
2022-04-18 12:53 |
Anonymous (not verified) |
204.16.59.10 |
Iowa’s Gutter Specialist LLC |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Heather Halverson |
Michael Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Heather Marie Halverson |
Michael Alexander Halverson |
Signed |
222 |
2020-08-03 16:16 |
Anonymous (not verified) |
204.98.109.114 |
Norval Craig Michael |
Proprietorship |
640 NE 47th Place, Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-20 |
Norval Craig Michael |
accounts@dickersonmechanical.com |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nornal Craig Michael |
accounts@dickersonmechanical.com |
Self Employeed - Sole Proprietor |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
412 |
2021-02-23 14:23 |
Anonymous (not verified) |
205.185.135.176 |
Jeffrey Meyer |
Proprietorship |
118 1st St SE New Albin IA 52160 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-23 |
Jeffrey Meyer |
meyertimberservices@gmail.com |
New Albin |
Allamakee |
Iowa |
Michael Klug |
Kayla Snitker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Klug |
mike@aibme.com |
Insurance Agent |
Caledonia |
Houston |
Minnesota |
Jeffrey Meyer |
Kayla Snitker |
Signed |
536 |
2021-06-07 11:01 |
Anonymous (not verified) |
205.221.255.62 |
Mark Lile |
Limited Liability Partnership |
PO Box 36411 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-07 |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Lile |
Mark@ultimateautowash.com |
Employer |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
581 |
2021-07-22 14:29 |
Anonymous (not verified) |
205.221.255.62 |
MartinHumphrey |
Limited Liability Company |
Cummins Rd. Apt 202 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Martin Luverne Humphrey Jr. |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Ioea |
George Porter |
Gerald Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
George Porter |
Gerald Lund |
Signed |
967 |
2022-03-11 13:41 |
Anonymous (not verified) |
205.221.255.62 |
Bard Inspection Services LLC |
Limited Liability Company |
3207 W Van Buren Ave, Fairfield, IA 52556 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-11 |
Stephanie Bard |
bardfamily4@gmail.com |
Fairfield |
Jefferson |
IA |
Miranda Millhouse |
Justin Millhouse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Bard |
bard.inspections@gmail.com |
owner |
Fairfield |
Jefferson |
IA |
Miranda Millhouse |
Justin Millhouse |
Signed |
2095 |
2024-03-14 11:39 |
Anonymous (not verified) |
205.221.255.62 |
Trimble Lawncare And Landscaping |
Proprietorship |
215 Boundary Ave Middletown IA 52638 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-14 |
Kevin Blake Trimble |
rknhtrimble@yahoo.com |
Middletown |
Des Moines |
Iowa |
Katelyn Orth |
Shayla Taeger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Blake Trimble |
rknhtrimble@yahoo.com |
owner |
Middletown |
Des Moines |
Iowa |
Katelyn Orth |
Shayla Taeger |
Signed |
38 |
2020-01-18 12:15 |
Anonymous (not verified) |
206.109.174.199 |
BJS Frenchies, LLC |
Limited Liability Company |
20081 Highway J 46 Centerville Iowa 52544 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
J. Jamie Tracy |
jamiespuppies@yahoo.com |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce E Tracy |
jamiespuppies@yahoo.com |
Husband and Co Owner |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
914 |
2022-02-15 10:22 |
Anonymous (not verified) |
206.72.12.83 |
Custom Windows Plus |
Limited Liability Company |
1623 Rose Avenue Allendorf Iowa 51354 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-15 |
Elijah Zevenbergen |
elijah.zevenbergen@gmail.com |
Allendorf |
United States |
IA |
Andrea Johnson |
Brennan Krogman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elijah Zevenbergen |
elijah.zevenbergen@gmail.com |
Owner |
Allendorf |
United States |
IA |
Andrea Johnson |
Brennan Krogman |
Signed |
102 |
2020-03-25 11:23 |
Anonymous (not verified) |
206.72.14.249 |
Brandi Wehr |
Proprietorship |
123 E Marion St, Sigourney, IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-25 |
Brandi Jo Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chelsea Voss |
chelsea@grimmrealestate.com |
Agent |
North English |
Iowa |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
108 |
2020-04-01 16:50 |
Anonymous (not verified) |
206.72.23.71 |
Heartland Renovations, LLC |
Limited Liability Company |
50253 290th Street, Kelley, IA 50134 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-01 |
Troy Van Maaren |
almostanything2@gmail.com |
Kelley |
Iowa |
United States |
Tammy J Reid |
Todd L Greenslit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Van Maaren |
almostanything2@gmail.com |
Member |
Kelley |
Story |
Iowa |
Tammy J Reid |
Todd L Greenslit |
Signed |
583 |
2021-07-23 12:37 |
Anonymous (not verified) |
206.72.45.27 |
S&L Finishers LLC |
Limited Liability Company |
307 N 5th Street Mallard Ia 50562 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-23 |
Luke AKRIDGE |
akridgel@ncn.net |
Mallard |
Palo Alto |
United States |
Kennedy Origer |
Andy Wiita |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke AKRIDGE |
akridgel@ncn.net |
Owner |
MALLARD |
IA |
United States |
Kennedy Origer |
Andy Wiita |
Signed |
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 |
1063 |
2022-04-21 08:23 |
Anonymous (not verified) |
207.155.112.81 |
Prudenterra, LLC |
Limited Liability Company |
65584 260th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-04-21 |
Luke Robert Gran |
luke@prudenterra.com |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Luke Robert Gran |
luke@prudenterra.com |
Self |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
984 |
2022-03-18 11:34 |
Anonymous (not verified) |
207.177.116.48 |
Craig Jacoba Signs |
Proprietorship |
20404 Walnut Street Yarmouth, IA 52660 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-18 |
Craig Allan Jacoba |
craigjacoba1@hotmail.com |
Yarmouth |
Des Moines |
Iowa |
Amy Moyner |
Brenda Levitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Jacoba |
craigjacoba1@gmail.com |
subcontractor |
Yarmouth |
Des Moines |
Iowa |
Amy Moyner |
Brenda Levitt |
Signed |
985 |
2022-03-18 11:39 |
Anonymous (not verified) |
207.177.116.48 |
Craig Jacoba Signs |
Proprietorship |
20404 Walnut Street Yarmouth, IA 52660 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-18 |
Craig Allan Jacoba |
craigjacoba1@hotmail.com |
Yarmouth |
Des Moines |
Iowa |
Amy Moyner |
Brenda Levitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greater Burlington Partnership - Chamber of Commerce |
amoyner@greaterburlington.com |
subcontractor |
Burlington |
Des Moines |
Iowa |
Amy Moyner |
Brenda Levitt |
Signed |
1191 |
2022-07-07 12:15 |
Anonymous (not verified) |
207.177.48.254 |
Day Ag Service LLC |
Proprietorship |
28250 240th Street Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-07 |
Calvin Brewer Day |
cal.d.day@gmail.com |
Dallas Center |
Dallas |
IA |
Dale Day |
Mary Beth Day |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Calvin Brewer Day |
cal.b.day@gmail.com |
Self |
Dallas Center |
Dallas |
IA |
Dale Day |
Mary Beth Day |
Signed |
284 |
2020-10-21 12:52 |
Anonymous (not verified) |
207.177.50.27 |
Luke Croghan |
Proprietorship |
2404 2200th street ,Manilla Ia. 51454 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
luke F Croghan |
croghanluke@gmail.com |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luke F Croghan |
croghanluke@gmail.com |
Owner |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
456 |
2021-04-02 10:02 |
Anonymous (not verified) |
207.177.7.191 |
Goettsch Dispatch Inc |
Limited Liability Company |
200 Main St Galva, IA 51020 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-15 |
Andrew Goettsch |
andygoettsch@gmail.com |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Goettsch |
andygoettsch@gmail.com |
President |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
889 |
2022-02-03 14:52 |
Anonymous (not verified) |
207.177.96.173 |
Stecker Rentals Inc. |
Limited Liability Company |
1439 Kate Shelley Dr. Boone IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-03 |
Holly Stecker |
hollystecker6@gmail.com |
Boone |
Boone |
IA |
Shana Mallas |
Laura Hutchcroft |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Holly Stecker |
hollystecker6@gmail.com |
Owner |
Boone |
Boone |
IA |
Shana Mallas |
Laura Hutchcroft |
Signed |
250 |
2020-09-01 12:08 |
Anonymous (not verified) |
207.191.193.167 |
Jairo Varela Roofing |
Proprietorship |
1681 Tofting Ave, Iowa City, IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Jairo Servellon Varela |
olvinlanza06@gmail.com |
Iowa City |
Johnson |
IA |
Jessica Lopez |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jairo Varela |
olvinlanza06@gmail.com |
Same |
Iowa City |
Johnson |
IA |
Jessica Lopez |
Anthony Johnson |
Signed |
487 |
2021-04-20 11:10 |
Anonymous (not verified) |
207.191.193.167 |
Chento Construction |
Proprietorship |
702 Lincoln St. Ainsworth, IA 52201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-05 |
Alberto Garcia |
chentoconstruction@hotmail.com |
Ainsworth |
Washington |
Iowa |
Anthony Johnson |
Jessica Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alberto Garcia |
chentoconstruction@hotmail.com |
Owner |
Ainsworth |
Washington |
Iowa |
Anthony Johnson |
Jessica Lopez |
Signed |
444 |
2021-03-22 16:26 |
Anonymous (not verified) |
207.191.204.10 |
Robert G. Wright Jr, |
Proprietorship |
2721 Elm St Dubuque, IA 52001 PO Box 475 Dubuque, IA 52004 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-20 |
Robert G. Wright Jr, |
robertw1963@gmail.com |
Dubuque |
Dubuque |
Iowa |
Brian Kregal |
Lynda Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert G. Wright Jr, |
robertw1963@gmail.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Brian Kregel |
Lynda Howell |
Signed |
857 |
2022-01-26 16:27 |
Anonymous (not verified) |
207.199.212.86 |
Grahm's Tree Service |
Proprietorship |
406 2nd Ave Charles City, IA 50616 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Graham Kuethe |
lacy@cioia.com |
Charles City |
Floyd |
Iowa |
Lacy Carolan |
Tony Trower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Graham Kuethe |
lacy@cioia.com |
Owner |
Charles City |
Floyd |
Iowa |
Lacy Carolan |
Tony Trower |
Signed |
867 |
2022-01-28 12:19 |
Anonymous (not verified) |
207.199.212.86 |
Gary Elsbernd DBA RGM Dairy Farm |
Proprietorship |
1538 230th St Calmar IA, 52132 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-21 |
Gary Elsbernd |
lacy@cioia.com |
Calmar |
Winneshiek |
Iowa |
Joel Rochford |
Lacy Carolan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Elsbernd |
lacy@cioia.com |
Self |
Calmar |
Winneshiek |
Iowa |
Joel Rochford |
Lacy Carolan |
Signed |
868 |
2022-01-28 12:22 |
Anonymous (not verified) |
207.199.212.86 |
Gary Elsbernd DBA RGM Dairy Farm |
Proprietorship |
1538 230th St Calmar IA, 52132 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-21 |
Marie Elsbernd |
lacy@cioia.com |
Calmar |
Winneshiek |
Iowa |
Joel Rochford |
Lacy Carolan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marie Elsbernd |
lacy@cioia.com |
Spouse |
Calmar |
Winneshiek |
Iowa |
Joel Rochford |
Lacy Carolan |
Signed |
843 |
2022-01-20 07:48 |
Anonymous (not verified) |
207.199.230.75 |
Heart of Iowa Inspections LLC |
Limited Liability Company |
2700 Highway 63 Oskaloosa, Iowa 52577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-20 |
Randy DeHeer |
rdenheer2828@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy DeHeer |
rdenheer2828@gmail.com |
self |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
934 |
2022-02-23 12:13 |
Anonymous (not verified) |
207.199.230.75 |
Randy DeHeer |
Limited Liability Company |
2700 Highway 63 Oskaloosa, Iowa 52577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-23 |
Randy DeHeer |
rdeheer2828@gmail.com |
Oskaloosa |
Mahaska |
Jowa |
Cheryl Brown |
Doris Crile |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy DeHeer |
rdeheer2828@gmail.com |
Self |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
959 |
2022-03-09 10:30 |
Anonymous (not verified) |
207.199.231.172 |
Steve Shepherd |
Proprietorship |
332 N Walnut St Fremont, IA 52561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-09 |
Steve Shepherd |
sheps2s69@gmail.com |
Fremont |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Shepherd |
sheps2s69@gmail.com |
Self |
Fremont |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
961 |
2022-03-09 15:06 |
Anonymous (not verified) |
207.199.231.172 |
Scott Ullrick |
Proprietorship |
601 Grant St Beacon, IA 52534 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-09 |
Scott Ullrick |
scottullrick@msn.com |
Beacon |
Mahaska |
IA |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Ullrick |
scottullrick@msn.com |
Self |
Beacon |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
962 |
2022-03-09 16:45 |
Anonymous (not verified) |
207.199.231.172 |
Thomas Whitehead |
Proprietorship |
1602 Green St Oskaloosa, IA 52577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-09 |
Thomas Whitehead |
roctomjj@mahaska.org |
Oskaloosa |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Whitehead |
roctomjj@mahaska.org |
Self |
Oskaloosa |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
980 |
2022-03-16 09:38 |
Anonymous (not verified) |
207.199.231.172 |
Sean Wursta |
Proprietorship |
401 Strawberry St Eddyville, IA 52553 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-16 |
Sean Wurstra |
5wurstas@gmail.com |
Eddyville |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Self |
5wurstas@gmail.com |
self |
Mahaska |
Eddyville |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
1011 |
2022-03-28 10:25 |
Anonymous (not verified) |
207.199.231.172 |
Brian Carmer |
Proprietorship |
133 S Iowa Ave, Ottumwa, IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
Brian Carmer |
b_carmer@yahoo.com |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Carmer |
B_Carmer@yahoo.com |
Self |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
951 |
2022-03-05 07:53 |
Anonymous (not verified) |
207.32.3.98 |
Larson Transport Systems |
Limited Liability Company |
3055 Maple Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-05 |
Spencer Larson |
spenlarson@gmail.com |
Forest City |
IA |
United States |
Mike Larson |
Sandy Larson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Larson |
spenlarson@gmail.com |
owner |
Forest City |
IA |
United States |
Mike Laron |
Sandy Larson |
Signed |
971 |
2022-03-14 17:59 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
972 |
2022-03-14 18:01 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Abby Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Glendenning |
lanceandabby@wccta.net |
President |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
973 |
2022-03-14 18:02 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Terry Glendenning |
happysower4@gmail.com |
Davis Junction |
Ogle |
Illinois |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Glendenning |
lanceandabby@wccta.net |
President |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
974 |
2022-03-14 18:04 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Tamara Glendenning |
happysower4@gmail.com |
Davis Junction |
Ogle |
Illinois |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Glendenning |
lanceandabby@wccta.net |
President |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
1078 |
2022-04-28 16:04 |
Anonymous (not verified) |
207.32.54.103 |
Juilfs Trucking |
Proprietorship |
709 S Geneva St. Pomeroy, IA 50575 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-28 |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Pomeroy |
Calhoun |
Iowa |
Lorie Gerdes |
Autumn Ramthun |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Myself |
Pomeroy |
IA |
United States |
Lorie Gerdes |
Autumn Ramthun |
Signed |
1020 |
2022-03-29 16:53 |
Anonymous (not verified) |
207.32.60.144 |
J.A. Dahlhauser, Ltd. |
Proprietorship |
1741 Hwy. 7 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Jaylin A. Dahlhauser |
jaydahlhauser@gmail.com |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaylin A. DAhlhauser |
jaydahlhauser@gmail.com |
Owner |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
1155 |
2022-06-14 12:44 |
Anonymous (not verified) |
207.45.82.36 |
GREEN AND SHINE SERVICES INC |
Proprietorship |
210 Ne 41st st Apt 203 Ankeny, IA, 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-14 |
ALEX A. LOPEZ REDONDO |
greenandshineservices@gmail.com |
ankeny |
polk |
iowa |
Giselle roa |
Marta casado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex A Lopez Redondo |
greenandshineservices@gmail.com |
propery |
ankeny |
polk |
iowa |
Giselle Roa |
Marta Casado |
Signed |
880 |
2022-02-01 14:05 |
Anonymous (not verified) |
207.45.88.5 |
Known Labs LLC |
Limited Liability Partnership |
8350 Ep True Pkwy, UNIT 1201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-01 |
Marcus Antonio Smith |
mark@knownlabs.net |
West Des Moines |
Dallas |
IA |
Dan Morgan III |
Amber Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcus Antonio Smith |
mark@knownlabs.net |
Owner |
West Des Moines |
IA |
IA |
Daniel Morgan III |
Amber Smith |
Signed |
697 |
2021-10-28 15:30 |
Anonymous (not verified) |
208.126.114.236 |
bartman express |
Limited Liability Company |
1976 240th st bennett iowa 52721 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-28 |
bartin joesph steines |
bartmanexpress@gmail.com |
bennett |
cedar |
iowa |
Robert theordore jarrett |
dana marie shipler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
bartin joesph steines |
bartmanexpress@gmail.com |
self |
bennett |
cedar |
iowa |
robert theordore jarrett |
dana marie shipler |
Signed |
695 |
2021-10-26 17:22 |
Anonymous (not verified) |
208.126.118.243 |
Godes Farms Trucking LLC |
Limited Liability Company |
1698 270th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-26 |
Mitchel R Godes |
mitchelgodes@hotmail.com |
Delmar |
clinton |
iowa |
Dustin Kyarsgaard |
Mitch Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchel R Godes |
mitchelgodes@hotmail.com |
owner |
Delmar |
Clinton |
iowa |
Dustin KKyarsgaard |
Mitch Moore |
Signed |
322 |
2020-11-17 14:06 |
Anonymous (not verified) |
208.126.118.26 |
Wada Farms |
Limited Liability Company |
2428 270th st Grand Mound, IA 52751 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-17 |
Wade Smith |
wade.smith1110@gmail.com |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wada Farms |
wade.smith1110@gmail.com |
self |
Grand Mound |
clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
649 |
2021-09-21 13:15 |
Anonymous (not verified) |
208.126.118.26 |
Wade Smith DBA WADA Farms |
Proprietorship |
2428 270th st, Grand Mound, IA 52751 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-09-21 |
Wade Smith |
wade.smith1110@gmail.com |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wade Smith |
wade.smith1110@gmail.com |
self |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
666 |
2021-10-07 08:12 |
Anonymous (not verified) |
208.126.166.149 |
Toribio Construction LLC |
Limited Liability Company |
107 W Maxson Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-07 |
Jose Toribio |
osorioabigail0224@gmail.com |
West Liberty |
Muscatine |
IA |
Anthony Johnson |
Abigail Osorio |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Toribio |
osorioabigail0224@gmail.com |
Owner |
West Liberty |
Muscatine |
IA |
Anthony Johnson |
Abigail Osorio |
Signed |
919 |
2022-02-16 21:13 |
Anonymous (not verified) |
208.126.203.31 |
K & D Land Improvement, LLC |
Limited Liability Company |
2719 270th Street, Lehigh, Iowa 50557 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-16 |
Daniel Hansen |
dhansen@lvcta.com |
Lehigh |
Webster |
Iowa |
Karen Hansen |
Cathy Mickelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Hansen |
dhansen@lvcta.com |
Member |
Lehigh |
Webster |
Iowa |
Karen Hansen |
Cathy Mickelson |
Signed |
306 |
2020-11-02 20:31 |
Anonymous (not verified) |
208.126.30.236 |
foust lawn care llc |
Limited Liability Company |
2999 st charles rd st charles ia 50240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-05 |
stephen howard foust |
shfoust53@gmail.com |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
stephen howard foust |
shfoust53@gmail.com |
self |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
1151 |
2022-06-13 09:29 |
Anonymous (not verified) |
208.126.52.58 |
Ronald D. Heneke |
Proprietorship |
PO Box 114 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-13 |
Ronald D. Heneke |
rheneke@email.com |
Delmar |
Clinton |
Iowa |
Mary S. O’Dell |
Neal J. Damm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald D. Heneke |
rheneke@email.com |
Self |
Delmar |
Clinton |
Iowa |
Mary S. O’Dell |
Neal J. Damm |
Signed |
330 |
2020-12-03 08:11 |
Anonymous (not verified) |
208.126.61.46 |
Hometown Comfort Heating & Cooling, LLC. |
Limited Liability Company |
1855 280th St. Webster City, Ia. 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-03 |
Mason Ormesher |
hometowncomfortia@gmail.com |
Webster City |
IA |
United States |
Kylee Ormesher |
Karen Ostrem |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Ormesher |
hometowncomfortia@gmail.com |
Owner |
Webster City |
Hamilton |
Iowa |
Kylee Ormesher |
Karen Ostem |
Signed |
415 |
2021-03-01 17:06 |
Anonymous (not verified) |
208.126.61.78 |
Fryes Tree Service |
Proprietorship |
P.O. Box 244 Webster City, IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-01 |
Don Johnson |
fts.don@gmail.com |
Webster City |
Hamilton |
IA |
Jenna Shaw |
Tim Turner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Don Johnson |
fts.don@gmail.com |
Owner |
Webster City |
Hamilton |
IA |
Jenna shaw |
Tim Turner |
Signed |
845 |
2022-01-20 09:06 |
Anonymous (not verified) |
208.126.69.10 |
KenX Pest Control |
Limited Liability Company |
350 2nd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-20 |
Ken YARRINGTON |
kenxpestcontrol@hotmail.com |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kenneth Charles Yarrington |
kenxpestcontrol@hotmal.com |
Myself |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
1200 |
2022-07-11 19:24 |
Anonymous (not verified) |
208.126.69.118 |
CMG Safety |
Limited Liability Company |
325 1st st. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-11 |
Chace Michael Garner |
chgarner18@gmail.com |
Truro |
Madison |
Iowa |
Josh Tomkins |
Kirsten Schirm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Tompkins |
josh.thomkins@307safety.com |
Contractor |
Gillette |
Cambell |
Wyoming |
Chace Garner |
Kirsten Schirm |
Signed |
291 |
2020-10-25 11:06 |
Anonymous (not verified) |
208.126.69.94 |
self-employed |
Proprietorship |
PO Box 15, 430 E. Iowa St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-25 |
Steven Fisher |
fishersjk@gmail.com |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Fisher |
fishersjk@gmail.com |
same person |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
1161 |
2022-06-22 19:41 |
Anonymous (not verified) |
208.38.229.190 |
Samuel Perez |
Proprietorship |
6523 N Main Street Davenport IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-22 |
Samuel Perez |
samuelperez@live.com |
Davenport |
Scott |
Iowa |
Raven Perez |
Omar Sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samuel Perez |
samuelperez@live.com |
Self |
Davenport |
Scott |
Iowa |
Raven Perez |
Omar Sanchez |
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 |
1348 |
2022-10-28 10:19 |
Anonymous (not verified) |
208.38.230.122 |
HALSEY'S HOME IMPROVEMENTS, LLC |
Limited Liability Company |
126 SYCAMORE LANE, RIVERDALE, IOWA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-28 |
MONTY RAY HALSEY |
crickstic@gmail.com |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MONTY HALSEY |
crickstic@gmail.com |
SELF |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
602 |
2021-08-13 22:49 |
Anonymous (not verified) |
208.38.230.125 |
Granite & More |
Limited Liability Company |
4730, Tremont Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-14 |
Jin Chen |
clteam563@gmail.com |
Davenport |
IA |
United States |
Jin Chen |
Betty Song |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hong Le |
clteam563@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Jin Chen |
Betty Song |
Signed |
1216 |
2022-07-20 16:24 |
Anonymous (not verified) |
208.38.231.24 |
Leaf Filter |
Limited Liability Partnership |
866 40th ave Bettendorf IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-19 |
Savannah Taets |
savannahtaets@gmail.com |
Davenport |
Scott |
Iowa |
Savannah Taets |
Layman Miller |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jennifer Stricklett |
jennifer.stricklett@suracy.com |
Insurance agent |
Davenport |
Scott |
Iowa |
Savannah Taets |
Layman Miller |
Signed |
645 |
2021-09-18 09:47 |
Anonymous (not verified) |
208.68.114.238 |
CHL Roofing & Siding Inc |
Proprietorship |
509 1/2 E A 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. |
2021-09-18 |
Fabian Galvan Rodriguez |
fgalvanglez14@gmail.com |
West Liberty |
Muscatine |
Iowa |
Karina A Beltran |
Nereida Velez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fabian Galvan Rodriguez |
fgalvanglez14@gmail.com |
Self |
West Liberty |
Muscatine |
Iowa |
Karina A Beltran |
Nereida Velez |
Signed |
1402 |
2022-12-28 16:35 |
Anonymous (not verified) |
208.69.145.91 |
DeRonde Flooring Inc. |
Proprietorship |
3612 NW 178th Ct, Clive IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-28 |
Brian DeRonde |
derondeflooring@gmail.com |
Clive |
Dallas |
IA |
Brian DeRonde |
Courtney DeRonde |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian DeRonde |
derondeflooring@gmail.com |
Self |
Clive |
Dallas |
IA |
Brian DeRonde |
Courtney DeRonde |
Signed |
1007 |
2022-03-25 10:30 |
Anonymous (not verified) |
208.73.53.194 |
Cory Lehman |
Proprietorship |
2428 Keokuk Drive 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. |
2022-03-25 |
Cory Lehman |
corysfloors@hotmail.com |
Pella |
Marion |
Iowa |
Trisha K Klok |
Terri Van Ryswyk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Lehman |
corysfloors@hotmail.com |
Self |
Pella |
Marion |
Iowa |
Trisha K Klok |
Terri Van Ryswyk |
Signed |
920 |
2022-02-17 10:15 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Construction, LLC |
Limited Liability Company |
1154 Dennison Avenue, Fairbank, IA 50629 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Merle B. Miller |
accounting@robertseddy.com |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle B. Miller |
accounting@robertseddy.com |
Same person |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
924 |
2022-02-17 13:02 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Construction, LLC |
Limited Liability Company |
1154 Dennison Ave., Fairbank, IA 50629 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Henry O. Miller |
accounting@robertseddy.com |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle Miller |
accounting@robertseddy.com |
Same person |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
925 |
2022-02-17 13:07 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Construction, LLC |
Limited Liability Company |
1154 Dennison Ave., Fairbank, IA 50629 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Chester H. Borntrager |
accounting@robertseddy.com |
Hazleton |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle Miller |
accounting@robertseddy.com |
Same person |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
1017 |
2022-03-29 14:53 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Insulation, LLC |
Limited Liability Company |
1180 110th Street Fairbank, IA 50629 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Lester Kauffman |
bookkeeping@robertseddy.com |
Fairbank |
Buchanan |
Iowa |
Sarah Van Buren |
Julie Ohl |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lester Kauffman |
bookeeping@robertseddy.com |
Same |
Fairbank |
Buchanan |
Iowa |
Sarah Van Buren |
Julie Ohl |
Signed |
928 |
2022-02-17 19:46 |
Anonymous (not verified) |
208.83.187.211 |
Eric Marsh Trucking LLC |
Limited Liability Company |
1029 Davis Ave Westbrook MN 56183 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Eric Marsh |
emt78@yahoo.com |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Marsh |
emt78@yahoo.com |
Self |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
447 |
2021-03-24 14:09 |
Anonymous (not verified) |
208.90.15.53 |
Gabe Saenz, LLC |
Limited Liability Company |
PO Box 53 Humboldt, IA 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-24 |
Gabriel Saenz |
gsaenzh@gmail.com |
Humboldt |
Humboldt |
Iowa |
Lance DeWinter |
Cathy Schipull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gabriel Saenz |
gsaenzh@gmail.com |
Owner |
Humboldt |
Humboldt |
Iowa |
Lance DeWinter |
Cathy Schipull |
Signed |
161 |
2020-05-19 11:31 |
Anonymous (not verified) |
208.95.1.97 |
Paul McCoy DBA McCoy Contracting |
Proprietorship |
2806 Highway T47, Montour, Iowa 50173 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Paul McCoy |
paulrmccoy1969@gmail.com |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul McCoy |
paulrmccoy1969@gmail.com |
Owner |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
546 |
2021-06-22 15:41 |
Anonymous (not verified) |
208.95.1.97 |
BAJ FLOORING, LLC |
Limited Liability Company |
31533 CASTLE COURT, DYERSVILLE, IA. 52040 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-06-11 |
BRIAN JACQUE |
jacquebrian18@gmail.com |
DYERSVIILLE |
DUBUQUE |
IOWA |
STEPHEN J. SCHLUETER |
PAULA FITZGERALD |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
BRIAN JACQUE |
jacquebrian18@gmail.com |
LLC MEMBER |
DYSERSVILLE |
DUBUQUE |
IOWA |
STEPHEN J. SCHLUETER |
PAULA FITZGERALD |
Signed |
633 |
2021-09-08 10:35 |
Anonymous (not verified) |
208.95.1.97 |
BAJ Flooring, LLC |
Limited Liability Company |
31533 Castle Ct. Dyersville, IA. 52040-7600 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-09-08 |
Brian Jacque |
JacqueBrian18@gmail.com |
Dyersville |
Dubuque |
Iowa |
Stephen J. Schluter |
Paula Fitzgerald |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Brian A. Jacque |
JacqueBrian18@gmail.com |
LLC MEMBER |
Dyersville |
DUBUQUE |
IOWA |
Stephen J. Schlueter |
Stephen J. Schlueter |
Signed |
111 |
2020-04-06 16:04 |
Anonymous (not verified) |
209.152.124.33 |
SM Tile Design LLC |
Limited Liability Company |
670 Daybreak 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. |
2020-04-06 |
Samir Mulalic |
Smtiledesign@gmail.com |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samir Mulalic |
Smtiledesign@gmail.com |
Same |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |
652 |
2021-09-22 21:52 |
Anonymous (not verified) |
209.152.66.250 |
Robert Stutzman |
Limited Liability Company |
33784 Hwy 22 Keota, IA 25548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
Robert L Stutzman |
bnbstutzman@gmail.com |
Keota |
Keokuk |
Iowa |
Jo Edgington |
Amber Gent |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sandra K Stutzman |
iafarmgirl90@gmail.com |
Daughter |
Keota |
Keokuk |
Iowa |
Jo Edgington |
Amber Gent |
Signed |
855 |
2022-01-26 10:39 |
Anonymous (not verified) |
209.152.66.250 |
Robert L Stutzman |
Limited Liability Company |
33784 Hwy 22 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-26 |
Robert L Stutzman |
bnbstutzman@gmail.com |
Keota |
Iowa |
United States |
Dasha Hesseltine |
Janette Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sandra Stutzman |
iafarmgirl90@gmail.com |
Daughter |
Keota |
Iowa |
United States |
Dasha Hesseltine |
Janette Miller |
Signed |
106 |
2020-03-31 10:42 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-31 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
107 |
2020-03-31 10:47 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-31 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
461 |
2021-04-06 08:49 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-06 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
462 |
2021-04-06 08:56 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven,IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-06 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
975 |
2022-03-15 10:34 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-15 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
976 |
2022-03-15 10:44 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-15 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
1217 |
2022-07-21 06:51 |
Anonymous (not verified) |
209.152.88.53 |
Bullard Accounting Services, LLC |
Limited Liability Company |
4519 Scouts View Dr, Central City, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Michael Bullard |
mikeandkarenbullard@gmail.com |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Bullard |
mikeandkarenbullard@gmail.com |
President of Company |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
714 |
2021-11-05 11:16 |
Anonymous (not verified) |
209.252.172.87 |
Branson Bult - Bults Flooring |
Proprietorship |
440 Memorial Dr Se Cedar Rapids, Ia 52403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-16 |
Branson Bult |
bultsfloorcovering@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Branson Bult |
bultsfloorcovering@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
715 |
2021-11-05 11:27 |
Anonymous (not verified) |
209.252.172.87 |
Ken Clifford |
Proprietorship |
132121st Ave SW Cedar Rapids, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-18 |
Ken Clifford |
ken40406108@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ken Clifford |
ken40406108@gmail.com |
Self Employer |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
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 |
717 |
2021-11-05 13:32 |
Anonymous (not verified) |
209.252.172.87 |
Nick Wiles CW Flooring LLC |
Limited Liability Company |
Po Box 445, 710 6th St Wellman, IA 52356 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-24 |
Nick Wiles CW Flooring LLC |
nickwiles007@gmail.com |
Wellman |
Washington |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Wiles CW Flooring LLC |
nickwiles007@gmail.com |
Self Employed |
Wellman |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
718 |
2021-11-05 13:41 |
Anonymous (not verified) |
209.252.172.87 |
Wayne Hunt |
Proprietorship |
405 E 4th St Tipton, Ia 52772 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-12 |
Wayne Hunt |
installation@bachmeiercarpetone.com |
Tipton |
Cedar |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wayne Hunt |
installation@bachmeiercarpetone.com |
Self |
Tipton |
Cedar |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
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 |
721 |
2021-11-05 14:04 |
Anonymous (not verified) |
209.252.172.87 |
Mike Kraus |
Proprietorship |
212 2nd St Buffalo, Ia 52728 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-17 |
Mike Kraus |
mjkraus4356@gmail.com |
Buffalo |
Scott |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Kraus |
mjkraus4356@gmail.com |
Self Employed |
Buffalo |
Scott |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
722 |
2021-11-05 14:07 |
Anonymous (not verified) |
209.252.172.87 |
Jeremiah Lunsford |
Proprietorship |
624 Carroll Dr SE, Cedar Rapids, IA 52403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-10 |
Jeremiah Lundsford |
jjaylunsford@gmail.com |
Cedar Paids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah Lunsford |
jjaylunsford@gmail.com |
Self Employed |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
723 |
2021-11-05 14:13 |
Anonymous (not verified) |
209.252.172.87 |
Will Lacina Northstar Hardwood Floors |
Proprietorship |
1211 G St Amana, IA 52203 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-16 |
Will Lacina |
northstarhardwoodfloor@gmail.com |
Amana |
Iowa |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Lacina |
northstarhardwoodfloor@gmail.com |
Self Employed |
Amana |
Iowa |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
724 |
2021-11-05 14:25 |
Anonymous (not verified) |
209.252.172.87 |
Josh Peterson |
Proprietorship |
121 Karen Drive, Williamsburg, IA 52361 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-15 |
Josh Peterson |
tanyataz@msn.com |
Williamsburg |
Iowa |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Peterson |
tanyataz@msn.com |
Self Employed |
Williamsburg |
Iowa |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
728 |
2021-11-05 14:52 |
Anonymous (not verified) |
209.252.172.87 |
Stacy Wade Wade Flooring Specialist |
Proprietorship |
2481 247th St, Washington, IA 52353 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Stacy Wade |
stacywade92@gmail.com |
Washington |
Washington |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Wade |
stacywade92@gmail.com |
Self |
Washington |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
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 |
1332 |
2022-10-12 20:44 |
Anonymous (not verified) |
209.252.174.114 |
Nelson Tile |
Proprietorship |
300 Shetland Dr. N.W. Cedar Rapids, Ia. 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. |
2022-10-12 |
Bruce Allen Nelson |
sherylnelson15@yahoo.com |
Cedar Rapids |
Linn |
Iowa |
Sheryl Marie Nelson |
Roger Eugene Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Allen Nelson |
sherylnelson@yahoo.com |
Owner,operator / same |
Cedar Rapids |
Linn |
Iowa |
Sheryl Marie Nelson |
Roger Eugene Nelson |
Signed |
824 |
2022-01-06 20:57 |
Anonymous (not verified) |
209.252.175.92 |
Rottweiler Remodel & Repair LLC |
Limited Liability Company |
1503 10th Ave Sw Cedar Rapids Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-06 |
Zechariah Robert DeLaVergne |
rottweilerremodel@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Kathy Maxine Morgan |
Daisha Rae Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zechariah DeLaVergne |
rottweilerremodel@gmail.com |
Owner |
Cedar Rapids |
Linn County |
Iowa |
Kathy Maxine Morgan |
daisha rae gonzalez |
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 |
208 |
2020-07-16 20:24 |
Anonymous (not verified) |
216.127.193.93 |
Sequoia Integrative Medical Services |
Limited Liability Company |
W2560 Birschbach Drive, Mount Calvary, WI, 53057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Chad Weston Gardner |
chadwestongardner@yahoo.com |
Mount Calvary |
Fond du Lac |
Wisconsin |
Emily Lucht |
Ron Carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Weston Gardner |
chadwestongardner@yahoo.com |
Self |
Mount Calvary |
Fond du Lac |
Wisconsin |
Emily Lucht |
Ron Carpenter |
Signed |
895 |
2022-02-04 11:57 |
Anonymous (not verified) |
216.189.133.155 |
A1A Sandblasting (Iowa) |
Proprietorship |
334 main street S.W. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-04 |
michael d marjama |
mike.orie@yahoo.com |
menahga |
MN |
United States |
Josh Louviere |
Kevin Tomperi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
michael d marjama |
mike.orie@yahoo.com |
Owner |
menahga |
MN |
United States |
Josh Louviere |
Kevin Tomperi |
Signed |
100 |
2020-03-24 15:46 |
Anonymous (not verified) |
216.51.130.87 |
Lake City Electric, LLC |
Limited Liability Company |
113 E Main Street, Lake City, IA 51449 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-24 |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
self |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
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 |
298 |
2020-10-30 10:45 |
Anonymous (not verified) |
216.51.132.207 |
Kregel Farm Partnership LLP |
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 |
Gary Kregel |
TRAVIS.KREGEL@GMAIL.COM |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Kregel |
TRAVIS.KREGEL@GMAIL.COM |
same |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
299 |
2020-10-30 10:47 |
Anonymous (not verified) |
216.51.132.207 |
Kregel Farm Partnership LLP |
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. |
2020-09-09 |
Darlene Kregel |
TRAVIS.KREGEL@GMAIL.COM |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darlene Kregel |
TRAVIS.KREGEL@GMAIL.COM |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
300 |
2020-10-30 10:51 |
Anonymous (not verified) |
216.51.132.207 |
Joe Kann & Luke Kann |
Partnership |
32256 Leaf 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. |
2020-10-28 |
Joe Kann |
kannbros1895@gmail.com |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joe Kann |
kannbros1895@gmail.com |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
301 |
2020-10-30 10:53 |
Anonymous (not verified) |
216.51.132.207 |
Joe Kann & Luke Kann |
Partnership |
32256 Leaf 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. |
2020-10-27 |
Luke Kann |
kannbros1895@gmail.com |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Kann |
kannbros1895@gmail.com |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
814 |
2021-12-27 13:07 |
Anonymous (not verified) |
216.51.155.17 |
I & B Ag Supply, LLC |
Limited Liability Company |
3807 20th Ave Fenton, IA 50539 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-27 |
Israel Winter |
israel.winter@hotmail.com |
Fenton |
Kossuth |
Iowa |
Jonathan Gesink |
Benjamin Wiersma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Israel Winter |
israel.winter@hotmail.com |
Member |
Fenton |
Kossuth |
Iowa |
Jonathan Gesink |
Benjamin Wiersma |
Signed |
394 |
2021-02-11 13:32 |
Anonymous (not verified) |
216.51.194.37 |
Estherville Aviation, Inc. |
Limited Liability Company |
1672 425th Ave., Estherville, IA 51334 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Estherville |
Emmet |
Iowa |
Elizabeth Burton |
Steve Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Owner/president |
Estherville |
Emmet |
Iowa |
Steve Erickson |
Treven Carlson |
Signed |
1080 |
2022-04-29 08:59 |
Anonymous (not verified) |
216.51.225.18 |
Lee's Haul It & Property Care |
Proprietorship |
212 Village Dr #5, 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. |
2022-04-29 |
Tim Lee |
timclee160@gmail.com |
Tiffin |
Johnson |
Iowa |
Lee Krueger |
Aaron Oehring |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lee's Haul It & Property Care |
leeshaulit@gmail.com |
Owner |
Tiffin |
Johnson |
Iowa |
Tim Lee |
Aaron Oehring |
Signed |
1022 |
2022-03-30 15:08 |
Anonymous (not verified) |
216.51.227.123 |
Elite Business Cleaning |
Limited Liability Company |
1350 Kennel Ct Unit C2 north liberty IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-30 |
rogelio morales ortega |
info@elitebusinesscleaning.com |
iowa city |
johnson |
Iowa |
alma rosa ortega |
john Spencer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elite Business Cleaning |
info@elitebusinesscleaning.com |
Ownerr |
iowa city |
johnson |
iowa |
Alma Rosa Ortega |
John Spender |
Signed |
1307 |
2022-09-14 13:40 |
Anonymous (not verified) |
216.51.227.123 |
elite business ckeaning |
Proprietorship |
1350 kennel ct unit c2 north liberty IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-14 |
rogelio morales ortega |
info@elitebusinesscleaning.com |
iowa city |
johnson |
iowa |
cesar morales ortega |
alma rosa perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
elite busibess cleaning |
info@elitebusinesscleaning.com |
president |
north liberty |
johnson |
iowa |
karina aguilar |
jessica lee |
Signed |
165 |
2020-05-26 14:12 |
Anonymous (not verified) |
216.51.228.161 |
Arbor Way All About Trees |
Limited Liability Company |
417 Howard St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-26 |
Nicholas Plumski |
arborway14@gmail.com |
Saint Anthony |
Marshall |
Iowa |
Michael Richards |
Nicole Plumski |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Plumski |
arborway14@gmail.com |
Owner |
St. Anthony |
Marshall |
IA |
Michael Richards |
Nicole Plumski |
Signed |
1127 |
2022-05-25 18:12 |
Anonymous (not verified) |
216.51.235.160 |
Midwest Excavation & Trucking LLC |
Limited Liability Company |
21324 Spring Ave Clarksville, Ia 50670 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-25 |
Jared Stephen Ragsdale |
Midwest.excavation.llc@gmail.com |
Clarksville |
Butler |
Iowa |
Dave Johnson |
Patrick Lursen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Stephen Ragsdale |
Midwest.excavation.llc@gmail.com |
Myself |
Clarksville |
Butler |
Iowa |
Dave Johnson |
Patrick Lursen |
Signed |
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 |
940 |
2022-03-01 11:08 |
Anonymous (not verified) |
216.51.251.31 |
trent montgomery trucking llc |
Limited Liability Company |
1432 eagle ridge circle pierce ne 68767 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-01 |
trent montgomery |
trent.montgomery7@gmail.com |
pierce |
pierce |
nebraska |
warren montgomery |
travis montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
trent montgomery |
trent.montgomery7@gmail.com |
self |
pierce |
pierce |
nebraska |
warren douglas montgomery |
travis warren montgomery |
Signed |
466 |
2021-04-08 09:58 |
Anonymous (not verified) |
216.81.153.249 |
Supreme Express Transport LLC |
Limited Liability Company |
609 Euclid Ave, Cherokee, IA 51012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-10 |
Liana Gil |
liana2702@gmail.com |
Cherokee |
Cherokee |
Iowa |
Leigh Laven |
Jared Brashears |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Gill |
liana2702@gmail.com |
Owner |
Cherokee |
Cherokee |
Iowa |
Leigh Laven |
Jared Brashears |
Signed |
1153 |
2022-06-13 16:22 |
Anonymous (not verified) |
216.9.166.5 |
Ronald B Blakley |
Proprietorship |
2001 St Bridgets Rd 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. |
2022-06-08 |
Ronald B Blakley |
sanjahunt@gmail.com |
Solon |
Johnson |
Iowa |
Scott G Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald B Blakley |
Sanjahunt@gmail.com |
Owner |
Solon |
Johnson |
Iowa |
Scott G Freeman |
Dyan Kriener |
Signed |
89 |
2020-03-13 12:41 |
Anonymous (not verified) |
216.96.113.16 |
B’s Sweet Treats |
Proprietorship |
123 E Marion St. Sigourney IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-13 |
Brandi Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
IA |
Brandi |
Brandi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandi Wehr |
brndwehr54@hotmail.com |
Same |
Sigourney |
Keokuk |
IA |
Brandi |
Brandi |
Signed |
99 |
2020-03-23 16:47 |
Anonymous (not verified) |
216.96.116.78 |
B’s Sweet Treats |
Proprietorship |
21484 196th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-23 |
Brandi Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
IA |
Erik Wehr |
Brenda Workman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandi Wehr |
brndwrhr54@hotmail.com |
Self |
Sigourney |
Keokuk |
IA |
Brenda Workman |
Erik Wehr |
Signed |
886 |
2022-02-03 10:21 |
Anonymous (not verified) |
217.180.228.144 |
Flo + Friends, LLC |
Limited Liability Company |
52480 HWY 210 Slater, IA. 50244 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-03 |
Molly S Onken |
mollyaols@gmail.com |
Slater |
Story |
Iowa |
Pam Wilson |
Todd Wilson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Molly S Onken |
mollyaols@gmail.com |
self |
slater |
Story |
Iowa |
Pam Wilson |
Todd Wilson |
Signed |
854 |
2022-01-24 19:59 |
Anonymous (not verified) |
217.180.228.216 |
Hansen Installations |
Limited Liability Company |
109 NW Calista Ct. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-24 |
Brian D Hansen |
bdhansen33@gmail.com |
Grimes |
IA |
United States |
Laurie Mills |
Jaiden Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian D Hansen |
bdhansen33@gmail.com |
Self |
Grimes |
IA |
United States |
Laurie Mills |
Jaiden Nelson |
Signed |
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 |
1389 |
2022-12-11 12:36 |
Anonymous (not verified) |
24.149.1.5 |
Project Fix It LLC |
Limited Liability Company |
1303 Washington Street Cedar Falls 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. |
2022-12-12 |
Adam L Reiter |
adam.reiter@projectfixit.net |
Cedar Falls |
IA |
United States |
Jennifer Reiter |
Logan Reiter |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Project Fix It |
adam.reiter@projectfixit.net |
Owner |
Cedar Falls |
IA |
United States |
Jennifer Reiter |
Logan Reiter |
Signed |
27 |
2020-01-06 09:17 |
Anonymous (not verified) |
24.149.10.119 |
Miss Wonderful LLC |
Limited Liability Company |
216 Main St Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
Ann Eastman |
misswonderful216@gmail.com |
Cedar Falls |
Black Hawk |
IA |
Rachel Lee |
Ann Remmert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ann Eastman |
misswonderful216@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
IA |
Rachel Lee |
Ann Remmert |
Signed |
773 |
2021-11-24 14:48 |
Anonymous (not verified) |
24.149.18.237 |
The Ragged Edge Art Bar and Gallery |
Limited Liability Company |
504 Bluff Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-24 |
Kendra Wohlert |
kwohlert43@gmail.com |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendra Wohlert |
kwohlert43@gmail.com |
self |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
1398 |
2022-12-21 22:02 |
Anonymous (not verified) |
24.149.20.131 |
B's Lawn Care |
Limited Liability Company |
1118 Rainbow Drive, Cedar Falls, Iowa 50613, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-21 |
Brandon Ballenger |
lawncare.bee@gmail.com |
Cedar Falls |
Iowa |
United States |
Katie Ballenger |
Tyler Ballenger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Ballenger |
lawncare.bee@gmail.com |
Owner/Operator |
Cedar Falls |
Iowa |
United States |
Katie Ballenger |
Tyler Ballenger |
Signed |
1236 |
2022-08-01 20:06 |
Anonymous (not verified) |
24.149.20.39 |
Jake's Insulation |
Proprietorship |
2020 Valley High Dr. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-01 |
Jacob Ryan Smalley |
jakersmalley@gmail.com |
Cedar Falls |
USA |
Iowa |
Emily Smalley |
Ben Smalley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Ryan Smalley |
jakersmalley@gmail.com |
Owner |
Cedar Falls |
USA |
Iowa |
Emily Smalley |
Ben Smalley |
Signed |
1003 |
2022-03-23 13:06 |
Anonymous (not verified) |
24.149.3.190 |
Thomas Wedmore |
Proprietorship |
200 State St, Ste 202G, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Cedar Falls |
IA |
United States |
Bradley Phillips |
Joshua Stafford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Self |
Reinbeck |
Grundy |
IA |
Bradley Phillips |
Joshua Stafford |
Signed |
1112 |
2022-05-17 14:15 |
Anonymous (not verified) |
24.162.40.106 |
Davis AG Service Texas LLC |
Limited Liability Company |
P.O. Box 1475 Fabens, Texas 79838 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-17 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Owner |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
1113 |
2022-05-17 14:20 |
Anonymous (not verified) |
24.162.40.106 |
John Anthony Davis |
Proprietorship |
P.O. Box 2551 Mountain View, AR 72560 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-17 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Proprietor |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
1330 |
2022-10-11 10:59 |
Anonymous (not verified) |
24.252.38.219 |
XXX |
Limited Liability Company |
XXX |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-15 |
XXX |
XXX@gmail.com |
XX |
XXX |
XXX |
XXX |
XXX |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
XXX |
XXX@gmail.com |
XXX |
XXX |
XXX |
XXX |
XXX |
XXX |
Signed |
467 |
2021-04-10 12:21 |
Anonymous (not verified) |
24.252.54.168 |
Dave and Nancy Preucil Inc. |
Proprietorship |
13585 Clearview Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-10 |
Domenico Zurini II |
davesspeedwaydz@gmail.com |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbi Zurini |
bzurini@gmail.com |
Wife |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
1079 |
2022-04-28 16:18 |
Anonymous (not verified) |
3.217.29.203 |
John Paul Pokorny |
Proprietorship |
500 W Adams St., Creston, 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. |
2022-02-04 |
John Paul Pokorny |
tylerins@tyleriowa.com |
Creston |
Union |
Iowa |
Jacquie Merritt |
Wendi Eslinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Paul Pokorny |
tylerins@tyleriowa.com |
Owner |
Creston |
Union |
Iowa |
Jacquie Merritt |
Wendi Eslinger |
Signed |
977 |
2022-03-15 12:04 |
Anonymous (not verified) |
38.108.136.192 |
Gunner Fogle |
Proprietorship |
307 S. Franklin St. Corydon, IA 50060 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-15 |
Gunner Lee Fogle |
gunnerfogle@hotmail.com |
Corydon |
Wayne |
IA |
Jeremy Fogle |
Erika Fogle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gunner Fogle |
gunnerfogle@hotmail.com |
Myself |
Corydon |
Wayne |
IA |
Jeremy Fogle |
Erika Fogle |
Signed |
1062 |
2022-04-20 06:46 |
Anonymous (not verified) |
38.121.112.209 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Timothy Slobodnik |
cabinetsandclosetsbydesign@gmail.com |
Council Bluffs |
Pottawattamie |
IA |
Tom Pieper |
Jim Sietsema |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Slobodnik |
cabinetsandclosetsbydesign@gmail.com |
self |
Council Bluffs |
Pottawattamie |
IA |
Tom Pieper |
Jim Sietsema |
Signed |
1294 |
2022-09-04 18:09 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-04 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
1414 |
2023-01-07 22:14 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Proprietorship |
18409 250th Street, 430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-07 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
437 |
2021-03-16 18:31 |
Anonymous (not verified) |
38.121.121.16 |
Thompsen Irrigation |
Proprietorship |
16086 Missouri Ave Crescent IA 51526 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-17 |
James R Thompsen |
jthom76285@aol.com |
Crescent |
Pottawattamie |
Iowa |
Mike Harmon |
Ilene Harmon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James R Thompsen |
jthom76285@aol.com |
self |
Crescent |
Pottawattamie |
Iowa |
Mike Harmon |
Ilene Harmon |
Signed |
1108 |
2022-05-16 16:14 |
Anonymous (not verified) |
4.4.30.34 |
David Sickels |
Proprietorship |
2221 Radcliffe Drive SW, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
David Sickels |
glsickels@gmail.com |
Cedar Rapids |
IA |
United States |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Allen Sickels |
glsickels@gmail.com |
self |
Cedar Rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
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 |
26 |
2020-01-04 17:23 |
Anonymous (not verified) |
45.53.67.52 |
Gary De Jager |
Limited Liability Company |
417 florida Ave NW Orange City Iowa 51041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-04 |
Gary Dean De Jager |
mightyspear60@yahoo.com |
Orange City |
Souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Dean De Jager |
mightyspear60@yahoo.com |
owner |
Orange City |
souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
1281 |
2022-08-24 11:06 |
Anonymous (not verified) |
47.185.154.197 |
Zachary Bobo |
Proprietorship |
2116 Newport Dr. Flower Mound, Tx. 75028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-24 |
Zachary Bobo |
ryan.zac@yahoo.com |
Flower Mound |
Denton |
Texas |
Kieth Volquardsen |
Chris Ventimiglia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Bobo |
ryan.zac@yahoo.com |
Self |
Flower Mound |
Denton |
Texas |
Kieth Volquardsen |
Chris Ventimiglia |
Signed |
87 |
2020-03-11 15:42 |
Anonymous (not verified) |
50.105.78.41 |
Al's Aerial Spraying, LLC |
Limited Liability Company |
3473 N Shepardsville Rd, Ovid MI 48866 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-11 |
Albert Edward Schiffer |
Al400@aol.com |
Ovid |
Cliinton |
Michigan |
Seth Alexander |
Nicholas Crofoot |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Albert Edward Schiffer |
Al400@aol.com |
Boss |
Ovid |
Clinto |
Michigan |
Nicholas Crofoot |
Nicholas Crofoot |
Signed |
88 |
2020-03-11 15:45 |
Anonymous (not verified) |
50.105.78.41 |
Al's Aerial Spraying, LLC |
Limited Liability Company |
3473 N Shepardsville Rd, Ovid MI 48866 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-11 |
Michael Schiffer |
Mike502B@aol.com |
Ovid |
Clinton |
MI |
Seth Alexander |
Nicholas Crofoot |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Albert Schiffer |
Al400@aol.com |
employee |
Ovid |
Clinton |
Michigan |
Seth Alexander |
Nicholas Crofoot |
Signed |
806 |
2021-12-20 08:56 |
Anonymous (not verified) |
50.124.217.66 |
Lyndon L Giese dba G&G Farms Trucking |
Proprietorship |
402 St Olaf Ave S Canby, MN 56220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-20 |
Lyndon L Giese |
ldgiese@frontiernet.net |
Canby |
Yellow Medicine |
Minnesota |
Jeff Sinn |
Tiffany Gohr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lyndon L Giese |
ldgiese@frontiernet.net |
Owner |
Canby |
Yellow Medicine |
Minnesota |
Jeff Sinn |
Tiffany Gohr |
Signed |
1320 |
2022-09-22 18:01 |
Anonymous (not verified) |
50.33.24.168 |
John Miller Trucking |
Proprietorship |
2414 180th Avenue Porter MN 56280 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-22 |
John Patrick Miller |
jkmiller@frontiernet.net |
Porter |
Yellow Medicine |
Minnesota |
Lois Verhelst |
Tricia Bueltel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Patrick Miller |
jkmiller@frontiernet.net |
Self |
Porter |
Yellow Medicine |
Minnesota |
Lois Verhelst |
Tricia Bueltel |
Signed |
1325 |
2022-10-02 20:07 |
Anonymous (not verified) |
50.80.107.101 |
Hanson Custom Cleanup and Removal LLC |
Limited Liability Company |
1221 Fleur Dr. 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. |
2022-10-02 |
Jason Jacob Hanson |
jasonhanson1985@gmail.com |
Waterloo |
Blackhawk |
Iowa |
Cindy Shreve |
Jacob Ring |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Hanson |
jasonhanson1985@gmail.com |
Self |
Waterloo |
Blackhawk |
Iowa |
Cindy Shreve |
Jacob Ring |
Signed |
1364 |
2022-11-09 09:57 |
Anonymous (not verified) |
50.80.120.38 |
Egl Enterprises, Inc. |
Proprietorship |
314 2ND AVE NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-09 |
EUGENE G LARUE |
egl.enterprises.inc@gmail.com |
HAMPTON |
IA |
United States |
stephanie hofer |
aryel laRue |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
EUGENE G LARUE |
egl.enterprises.inc@gmail.com |
self |
HAMPTON |
IA |
United States |
stephanie hofer |
aryel laRue |
Signed |
1088 |
2022-05-04 16:00 |
Anonymous (not verified) |
50.80.16.238 |
American Gutter Company LLC |
Proprietorship |
2015 Andrew Charles Dr NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-04 |
John Kuper |
american.guttercompanyllc@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Kuper |
american.guttercompanyllc@gmail.com |
Owner |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
260 |
2020-09-17 10:52 |
Anonymous (not verified) |
50.80.218.18 |
Decanus Property Management |
Proprietorship |
102 E 2nd St, Davenport IA 52801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-17 |
Shonna Suzanne Dean |
decanus@yahoo.com |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shonna S Dean |
decanus@yahoo.com |
Self |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
1093 |
2022-05-12 06:32 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW, Cedar Rapids, IA 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. |
2022-02-01 |
Catarino Martinez Alvarez - H&C Roofing LLC |
handc.rconst@outlook.com |
North Liberty |
Johnson |
Iowa |
Evelyn Lagos |
Edgardo Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
Gsaunders@beastconstructioncr.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Laura Sturm |
Joanie Lacayo |
Signed |
1182 |
2022-07-06 13:40 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-11 |
Gilberto Vasquez (GV Construction LLC) |
Normambazquez@gmail.com |
Iowa City |
IA |
United States |
Pedro Pinto |
Rafael Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
gsaunders@beastconstructioncr.com |
Owner |
CEDAR RAPIDS |
IA |
United States |
Laura Saunders |
Joanie Lacayo |
Signed |
817 |
2021-12-30 12:58 |
Anonymous (not verified) |
50.80.80.37 |
Leaf Filter |
Limited Liability Company |
1595 Georgetown Road Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-30 |
Kenneth Van Hook |
kennyvanhook1976@gmail.com |
Port Byron |
Rock Island |
IL |
Sharon Van Hook |
Judy Hoffman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
cdunbar@leaffilter.com |
Manager |
Bettendorf |
Scott County |
IA |
Cody Dunbar |
Jordan Nisiewicz |
Signed |
1234 |
2022-08-01 16:55 |
Anonymous (not verified) |
50.80.97.166 |
Joshua Schumacher |
Proprietorship |
5801 timber creek rd ne |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-01 |
Josh Schumacher |
amjs2003@centurylink.net |
Cedar Rapids |
Iowa |
Iowa |
Karen Meroshek |
Philip McCurdy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Schumacher |
amjs2003@centurylink.net |
Self |
Cedar Rapids |
Iowa |
Iowa |
Katen Meroshek |
Philip McCurdy |
Signed |
1237 |
2022-08-01 22:40 |
Anonymous (not verified) |
50.80.97.239 |
Andy Fiala |
Proprietorship |
1628 34th St. NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-01 |
Andy W Fiala |
fialaandy1@gmail.com |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andy W Fiala |
fialaandy1@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
9 |
2019-12-16 11:33 |
Anonymous (not verified) |
50.81.115.85 |
Travis Garrett and Caleb Elliott |
Partnership |
P.O. Box 55, 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. |
2019-12-16 |
Travis Garrett |
onethird4599@gmail.com |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Garrett & Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
10 |
2019-12-16 11:35 |
Anonymous (not verified) |
50.81.115.85 |
Travis Garrett and Caleb Elliott |
Partnership |
P.O. Box 55, 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. |
2019-12-16 |
Caleb Elliott |
onethird4599@gmail.com |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Garrett & Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
615 |
2021-08-20 16:22 |
Anonymous (not verified) |
50.81.152.147 |
CPIA Home Specialists LLC |
Limited Liability Company |
1214 13th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
1397 |
2022-12-21 14:05 |
Anonymous (not verified) |
50.81.162.60 |
Jesse Iseminger |
Proprietorship |
3117 e 40th ct, Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-21 |
Jesse Iseminger |
Jesseiseminger@gmail.com |
Des Moines |
Polk |
Iowa |
Shelly Johns |
Brad Weikert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Iseminger |
Jesseiseminger@gmail.com |
Self |
Des Moines |
Iowa |
Iowa |
Shelly Johns |
Brad Weikert |
Signed |
1360 |
2022-11-04 11:13 |
Anonymous (not verified) |
50.81.34.190 |
Rescue 365 Towing & Salvage |
Limited Liability Company |
2569 58th St Vinton, IA 52349 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-04 |
Tyler Schwartz |
rescue365@hotmail.com |
VAN HORNE |
Benton |
IA |
Tony Harmon |
Tracy Beitz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Schwartz |
rescue365@hotmail.com |
Self |
Van Horne |
Benton |
IA |
Tony Harmon |
Tracy Beitz |
Signed |
522 |
2021-05-17 20:27 |
Anonymous (not verified) |
50.81.4.25 |
Crew Cut Lawn Care |
Limited Liability Company |
7820 1st Ave NW Cedar Rapids, IA 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. |
2021-05-17 |
Rupert McKendly Ellis |
wideglide94@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Adrian Pink |
Lorraine Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rupert M Ellis |
wideglide94@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Adrian Pink |
Lorraine |
Signed |
639 |
2021-09-13 16:10 |
Anonymous (not verified) |
50.81.97.207 |
Copic Home Maintenance LLC dba Des Moines Drywall Repair |
Limited Liability Company |
1548 24th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-13 |
Clint R Copic |
crcopic@gmail.com |
Des Moines |
Polk |
Iowa |
Veronica G. Torres |
Dan Waidelich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clint R Copic |
dmdrywallrepair@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Veronica G Torres |
Dan Waidelich |
Signed |
307 |
2020-11-04 14:43 |
Anonymous (not verified) |
50.82.130.211 |
ALL N DESIGNS, LLC |
Limited Liability Company |
601 Nicklaus Drive, 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. |
2020-10-23 |
Aimee Allan |
cmins_re@mchsi.com |
Parkersburg |
Butler |
iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aimee Allan |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
318 |
2020-11-16 15:06 |
Anonymous (not verified) |
50.82.130.211 |
Boulder Woodworks, LLC |
Limited Liability Company |
3011 Boulder Drive, Cedar Falls IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-28 |
Eric Simmons |
cmins_re@mchsi.com |
Cedar Falls |
Black Hawk |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Simmons |
cmins_re@mchsi.com |
Self |
Cedar Falls |
Black Hawk |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
361 |
2021-01-12 16:04 |
Anonymous (not verified) |
50.82.130.211 |
Gregory Lievens |
Partnership |
503 N. Main Street, Allison IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-12 |
Gregory Lievens |
cmins_re@mchsi.com |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gregory Lievens |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
383 |
2021-02-03 15:05 |
Anonymous (not verified) |
50.82.130.211 |
David Kuehner |
Proprietorship |
P.O. Box 158, Allison IA 50602 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-08 |
David Kuehner |
cmins_re@mchsi.com |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Kuehner |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
454 |
2021-03-26 09:46 |
Anonymous (not verified) |
50.82.130.211 |
Jason Thoren |
Proprietorship |
104 1st Street NW, Tripoli, IA 50676 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-04 |
Jason Thoren |
cmins_re@mchsi.com |
Tripoli |
Bremer |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Thoren |
cmins_re@mchsi.com |
Self |
Tripoli |
Bremer |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
503 |
2021-05-05 11:27 |
Anonymous (not verified) |
50.82.130.211 |
Davonius Reed |
Limited Liability Company |
1913 Upton Avenue, 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. |
2021-04-01 |
Davonius Reed |
cmins_re@mchsi.com |
Waterloo |
Black Hawk |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Davonius Reed |
cmins_re@mchsi.com |
Self |
Waterloo |
Black Hawk |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
520 |
2021-05-17 10:32 |
Anonymous (not verified) |
50.82.130.211 |
Madison Oldenburger |
Proprietorship |
809 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. |
2021-05-06 |
Madison Oldenburger |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Madison Oldenburger |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
525 |
2021-05-18 09:42 |
Anonymous (not verified) |
50.82.130.211 |
Adrian Bernard |
Proprietorship |
803 Russell Circle, 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. |
2021-05-07 |
Adrian Bernard |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Bernard |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Chad Campbell |
Signed |
566 |
2021-07-08 14:19 |
Anonymous (not verified) |
50.82.130.211 |
Black Cat Ice Cream, LLC |
Limited Liability Company |
1031 Office Park Road, Suite #4, 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. |
2021-06-10 |
David Boelman |
cmins_re@mchsi.com |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Black Cat Ice Cream, LLC |
cmins_re@mchsi.com |
Self |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
567 |
2021-07-08 14:22 |
Anonymous (not verified) |
50.82.130.211 |
Black Cat Ice Cream, LLC |
Limited Liability Company |
1031 Office Park Road, Suite #4, 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. |
2021-06-10 |
Alex Carter |
cmins_re@mchsi.com |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Black Cat Ice Cream, LLC |
cmins_re@mchsi.com |
Self |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
632 |
2021-09-07 13:42 |
Anonymous (not verified) |
50.82.130.211 |
Thomas Mann |
Proprietorship |
401 Miners Street, Parkersburg, 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. |
2021-09-09 |
Thomas Mann |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Mann |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
706 |
2021-11-02 11:45 |
Anonymous (not verified) |
50.82.130.211 |
Kierstyn Anest |
Proprietorship |
1200 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. |
2021-10-25 |
Kierstyn Anest |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kerstyn Anest |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
847 |
2022-01-20 13:54 |
Anonymous (not verified) |
50.82.130.211 |
Albatross Capital, LLC |
Limited Liability Company |
28003 290th Street, 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. |
2021-10-22 |
Jesse Nitcher |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Nitcher |
cmins_re@mchsi.com |
Member of LLC |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
848 |
2022-01-20 13:56 |
Anonymous (not verified) |
50.82.130.211 |
Albatross Capital, LLC |
Limited Liability Company |
28003 290th St., 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. |
2021-10-22 |
Chris Buseman |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Buseman |
cmins_re@mchsi.com |
Member of LLC |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
849 |
2022-01-20 13:58 |
Anonymous (not verified) |
50.82.130.211 |
Albatross Capital, LLC |
Limited Liability Company |
28003 290th St., 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. |
2021-10-22 |
Brandon Huisman |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Huisman |
cmins_re@mchsi.com |
Member of LLC |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
850 |
2022-01-20 14:03 |
Anonymous (not verified) |
50.82.130.211 |
Albatross Capital, LLC |
Limited Liability Company |
28003 290th St., 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. |
2021-10-22 |
Justin Mehmen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Mehmen |
cmins_re@mchsi.com |
Member of LLC |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
851 |
2022-01-20 14:10 |
Anonymous (not verified) |
50.82.130.211 |
Albatross Capital, LLC |
Limited Liability Company |
28003 290th St., 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. |
2021-10-22 |
Justin Mehmen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Mehmen |
cmins_re@mchsi.com |
Member of LLC |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
995 |
2022-03-22 14:40 |
Anonymous (not verified) |
50.82.130.211 |
Pietig Construction, LLC |
Limited Liability Company |
302 Brookside Dr, 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. |
2022-03-09 |
Joel Pietig |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Pietig |
cmins_re@mchsi.com |
Owner/Self |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
1393 |
2022-12-13 12:45 |
Anonymous (not verified) |
50.82.133.22 |
Ponderosa Outdoor |
Limited Liability Partnership |
104 Vista Dr Montezuma, Ia 50171 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-13 |
Daniel Deaver |
ponderosaoutdoor@gmail.com |
Altoona |
Polk |
Iowa |
Faith Deaver |
Jessi Perkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Deaver |
ponderosaoutdoor@gmail.com |
self |
Altoona |
Polk |
Iowa |
Faith Deaver |
Jessi Perkins |
Signed |
426 |
2021-03-09 09:31 |
Anonymous (not verified) |
50.82.173.179 |
Joshua Strong DBA Watson Excavation |
Proprietorship |
202 Lewis St Bedford, IA 50833 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-03-09 |
Joshua Strong |
joshandtanyastrong@yahoo.com |
Bedford |
Taylor |
IA |
Maggie Jackson |
Shella Baldwin |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tanya Strong |
tanya@farmandhomellc.com |
Spouse |
Bedford |
IA |
United States |
Maggie Jackson |
Shella Baldwin |
Signed |
1328 |
2022-10-07 22:45 |
Anonymous (not verified) |
50.82.178.112 |
Compass Commercial Services LLC |
Limited Liability Company |
1950 Boyson road, Hiawatha, Ia 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-07 |
Patrick Roland |
mastershineservices@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Fortanini |
bfontanini@compassbuilt.com |
Project Manager |
Hiawatha |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
1408 |
2023-01-04 16:12 |
Anonymous (not verified) |
50.82.188.217 |
Guerrero Masonry |
Proprietorship |
5003 Keystone Rdg SE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Jaime Guerrero |
jaime.guerrero@mchsi.com |
Cedar Rapids |
IA |
United States |
Susan Bender |
Larry Bender |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaime Guerrero |
jaime.guerrero@mchsi.com |
self |
CEDAR RAPIDS |
Linn |
Iowa |
Susan Bender |
Larry Bender |
Signed |
378 |
2021-01-29 11:43 |
Anonymous (not verified) |
50.82.21.136 |
GRAPHIX MASTERS |
Limited Liability Company |
420 Hamilton St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-01-29 |
Klayton Karl Kirkpatrick |
klay@graphixmasters.us |
Ottumwa |
IA |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Klayton Kirkpatrick |
klay@graphixmasters.us |
Same |
Ottumwa |
Iowa |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
519 |
2021-05-13 10:32 |
Anonymous (not verified) |
50.82.22.159 |
Southern Iowa Crane, Incorporated |
Proprietorship |
635 Mill Street; Ottumwa, IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-13 |
Steve Lee |
southerniowacraneinc@hotmail.com |
Ottumwa |
Wapello |
Iowa |
Brandon Gravett |
Sarah Gravett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Lee |
sotherniowacraneinc@hotmail.com |
Self |
Ottumwa |
Wapello |
Iowa |
Sarah Gravett |
Brandon Gravett |
Signed |
1293 |
2022-09-03 08:03 |
Anonymous (not verified) |
50.82.244.98 |
MTZ Drywall |
Proprietorship |
1101 Eighth St, West Des Moines, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-02 |
Richar Martinez |
menace_42@icloud.com |
West Des Moines |
United States |
Iowa |
Alejandro Gonzalez |
Emilio Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Jenkins |
jjenkins@farmersagent.com |
N/A |
Urbandale |
United States |
Iowa |
Alejandro Gonzalez |
Emilio Martinez |
Signed |
958 |
2022-03-08 20:17 |
Anonymous (not verified) |
50.82.39.158 |
Ramos Drywall |
Limited Liability Company |
1355 Ozark Ridge, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-03-08 |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
Coralville |
Iowa |
United States |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
N/A- Same Person |
Coralville |
Johnson County |
IA |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
608 |
2021-08-17 21:35 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
James D VanderBeek |
jvanderbeek@plbci.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
Zackery James VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Zackery J VanderBeek |
Signed |
609 |
2021-08-17 21:42 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
Zackery James VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
James. VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Barbara M VanderBeek |
Signed |
612 |
2021-08-19 21:50 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing,, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, Iowa 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
James Dean VanderBeek |
jvanderbeek@plbco.com |
New Sharon |
Mahaska |
Iowa |
Margaret Ratcliff |
Billy Blake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
Iowa |
Margaret Ratcliff |
Billy Blake |
Signed |
613 |
2021-08-19 21:54 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, Iowa 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Zackery J VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
532 |
2021-05-27 11:28 |
Anonymous (not verified) |
50.82.70.103 |
WHAT BBQ & BAR, LLC |
Limited Liability Company |
106 S CODY RD LECLAIRE, IA 52753 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-27 |
SHILL HUNTER |
WHATBBQBAR@GMAIL.COM |
LECLAIRE |
SCOTT |
IOWA |
WHITNEY LANE |
ROBERT CAIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHILL HUNTER |
WHATBBQBAR@GMAIL.COM |
OWNER |
LECLAIRE |
SCOTT |
IOWA |
WHITNEY LANE |
ROBERT CAIN |
Signed |
1264 |
2022-08-16 21:22 |
Anonymous (not verified) |
50.82.84.19 |
Nogotta Trucking LLC |
Limited Liability Company |
16617 Wilden Dr, Clive IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-16 |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Managing Member |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
1353 |
2022-10-31 21:35 |
Anonymous (not verified) |
50.82.84.225 |
Jerry Bassett |
Proprietorship |
108 NE 22 Cr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
Jerry Bassett |
JerryDebBassett@aol.com |
GRIMES |
IA |
United States |
Deb Bassett |
Jerry Bassett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Bassett |
JerryDebBassett@aol.com |
Self |
Grimes |
Polk |
Iowa |
Deb Bassett |
Jerry Bassett |
Signed |
1318 |
2022-09-22 11:18 |
Anonymous (not verified) |
50.82.91.213 |
J. Thompson Builders, LLC |
Limited Liability Company |
5291 Stoney Creek Ct. Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-22 |
Christopher Jacob Von Arx |
cjvonarx@hotmail.com |
Van Wert IA |
Decatur IA |
Iowa |
Christina Viehauser |
Jeremy Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christina Viehauser |
christina@jthompsonbuilders.com |
Office Help |
Johnston Ia |
Polk |
IA |
Chris Von Arx |
Jeremy Thompson |
Signed |
1319 |
2022-09-22 11:31 |
Anonymous (not verified) |
50.82.91.213 |
J. Thompson Builders, LLC |
Limited Liability Company |
5291 Stoney Creek Ct. Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-22 |
Mark Grant |
mjgrant1957@gmail.com |
Adel |
Dallas |
IA |
Christina Viehauser |
Jeremy Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christina Viehauser |
christina@jthompsonbuilders.com |
Office Help |
Johnston Ia |
Polk |
IA |
Chris Von Arx |
Jeremy Thompson |
Signed |
202 |
2020-07-10 15:30 |
Anonymous (not verified) |
50.82.95.247 |
Paulo De Oliveira |
Proprietorship |
466 Valeen In Belton, MO 64012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
1183 |
2022-07-06 13:43 |
Anonymous (not verified) |
50.82.95.247 |
2DL Construction, LLC |
Limited Liability Company |
1134 21st Street, Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-06 |
Diego Lopez |
calihernandez01@icloud.com |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Diego Lopez |
calihernandez01@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
1066 |
2022-04-22 11:17 |
Anonymous (not verified) |
50.83.107.151 |
Delos Steward |
Proprietorship |
1310 w Main Street Marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-22 |
Delos Lyle Steward |
LDSPlastering2020@gmail.com |
Marshalltown |
Marshall |
Iowa |
Chris Hart |
Jody Steward |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LDS Plastering |
ldsplastering2020@gmail.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Chris Hart |
Jody Steward |
Signed |
1058 |
2022-04-19 13:19 |
Anonymous (not verified) |
50.83.154.192 |
Property Maintenance Services of Iowa LLC |
Limited Liability Company |
PO Box 166 Low Moor IA 52757 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
Frederick Stewart |
curlyfry42000@yahoo.com |
LOW MOOR |
IA |
United States |
Irene R Stewart |
Derek S Jensen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frederick Lee Stewart |
zombiesby2012@gmail.com |
Owner |
Clinton |
IA |
United States |
Irene R Stewart |
Derek S Jensen |
Signed |
901 |
2022-02-06 16:48 |
Anonymous (not verified) |
50.83.154.236 |
Cole Jurgle |
Proprietorship |
409 West riverside drive prophetstown IL 61277 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-05 |
Cole Alexander Jurgle |
cole.jurgle@gmail.com |
Prophetstown |
Whiteside |
Illinois |
Nicholas Ray Jurgle |
Misty Ann Jurgle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cole Alexander Jurgle |
cole.jurgle@gmail.com |
self |
Prophetstown |
Whiteside |
Illinois |
Nicholas Ray Jurgle |
Misty Ann Jurgle |
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 |
709 |
2021-11-04 12:38 |
Anonymous (not verified) |
50.83.182.182 |
All Pro Painting LLC |
Limited Liability Company |
5431 Gear Street Prole Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-04 |
Tory Webb (United Trades Group LLC) |
toryw@unitedtradesgroup.org |
Norwalk |
Warren |
Iowa |
Ryan Drabek |
Dustin Kohler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Adams |
adam@allpropaintingdsm.com |
Project Manager |
Prole |
Warren |
Iowa |
Ryan Drabek |
Dustin Kohler |
Signed |
710 |
2021-11-04 12:57 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive 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. |
2020-11-04 |
Tory Webb |
torywebbdmi@gmail.com |
Norwalk |
Polk |
Iowa |
Ryan Drabek |
Dustin Kohler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Iowa |
United States |
Ryan Drabek |
Dustin Kohler |
Signed |
732 |
2021-11-09 15:25 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick 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. |
2021-11-09 |
Ryan Drabek |
ryand@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Dustin Kohler |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Warren |
Iowa |
Trevor Spidle |
Dustin Kohler |
Signed |
733 |
2021-11-09 15:35 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick 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. |
2021-11-09 |
Dustin Kohler |
dustink@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
torywebbdmi@gmail.com |
Owner, Management |
Norwalk |
Warren |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
11 |
2019-12-17 19:46 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Louis I. Maxwell |
brockbrooke2463@yahoo.com |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Louis Maxwell |
brockbrooke2463@yahoo.com |
Owner |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
12 |
2019-12-17 19:54 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Brock A Maxwell |
brock246393@gmail.com |
Des Moines |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brock A Maxwell |
brock246393@gmail.com |
Owner |
Des Moines |
POlK |
Iowa |
Yvonne Ginther |
Hope Winegardner |
Signed |
1232 |
2022-07-28 18:27 |
Anonymous (not verified) |
50.83.189.149 |
Eagle Construction Co LLC |
Limited Liability Company |
1150 county line rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-28 |
Carlos Flores |
eagleconstruciontco.865@gmail.com |
Des Moines |
Warren |
Iowa |
Morgan Conrard |
Ronika Htu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carlos Flores |
eagleconstruciontco.865@gmail.com |
Owner |
Des Moines |
Warren |
IA |
Morgan Conrard |
Ronika Htu |
Signed |
1053 |
2022-04-14 21:08 |
Anonymous (not verified) |
50.83.192.136 |
John E Snyder JR |
Proprietorship |
1677 PACIFIC ST, MURRAY, IA 50174 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
John Snyder JR |
jrsweldingia@gmail.com |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Snyder JR |
jrsweldingia@gmail.com |
Selg |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
Signed |
1288 |
2022-08-30 16:23 |
Anonymous (not verified) |
50.83.35.94 |
Black Rock Flooring LLC |
Limited Liability Company |
189 9th st. Marion,Ia 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-30 |
Keith Douglas Luye Sr. |
Blackrockflooriing@gmail.com |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Douglas Luye Sr. |
Blackrockflooring@gmail.com |
self / my own authorized agent |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
540 |
2021-06-08 21:40 |
Anonymous (not verified) |
50.83.39.243 |
Brightland Appraisal Group |
Limited Liability Company |
1348 Rolling Glen Dr. Marion IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-08 |
Eric Lamp |
eric.lamp@brightlandappraisal.com |
Marion |
Linn |
Iowa |
Sarah Lamp |
Linda Lamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Allen Lamp |
eric.lamp@brightlandappraisal.com |
Self |
Marion |
Linn |
Iowa |
Sarah Lamp |
Linda Lamp |
Signed |
1279 |
2022-08-22 13:17 |
Anonymous (not verified) |
50.83.54.168 |
Essex Family Construction |
Limited Liability Company |
290 Monmouth St SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Niki Essex |
essexfamilycontruction@outlook.com |
Cedar Rapids |
IA |
IA |
Josh Lasond |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niki Essex |
essexfamilycontruction@outlook.com |
same |
Cedar Rapids |
Iowa |
Iowa |
Josh Lasond |
Jordan Nisiewicz |
Signed |
235 |
2020-08-18 13:25 |
Anonymous (not verified) |
50.83.91.36 |
Tyler Abigt |
Proprietorship |
636 Crestview Ave Ottumwa, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-18 |
Tyler Abigt |
Abigtlettering@gmail.com |
Ottumwa |
Wapello |
Iowa |
Jonathan Strube |
Michelle Abigt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Abigt |
Abigtlettering@gmail.com |
Owner |
Ottumwa |
Wapello |
Iowa |
Jonathan Strube |
Michelle Abigt |
Signed |
1100 |
2022-05-13 12:54 |
Anonymous (not verified) |
50.83.96.157 |
Spindrift LLC |
Limited Liability Company |
2825 Newport Rd NE Iowa City IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-13 |
Nathaniel James Dooley |
spindriftlawnandsnow@gmail.com |
Iowa City |
Johnson |
Iowa |
Sharon Dooley |
Kristen Simpson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathaniel James Dooley |
spindriftlawnandsnow@gmail.com |
Same |
Iowa City |
Johnson |
Iowa |
Sharon Dooley |
Kristen Simpson |
Signed |
24 |
2020-01-03 12:41 |
Anonymous (not verified) |
63.152.13.239 |
Eden Plumbing LLC TJ Eden |
Limited Liability Company |
502 Packwaukee Street New Hartford, IA 50660 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-03 |
TJ Eden |
edentj@aol.com |
New Hartford |
IA |
United States |
Ann Robinson |
Nate Schmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PDCM Insurance- Nate Schmidt |
NSCHMIDT@PDCM.COM |
Member |
New Hartford |
Butler |
Iowa |
Ann Robinson |
Nate Schmidt |
Signed |
878 |
2022-01-31 12:37 |
Anonymous (not verified) |
63.152.234.243 |
It's a Breeze Cleaning Service |
Proprietorship |
760 W 8th Ave, Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-31 |
Breonna Kay Nelson |
breanderson82@yahoo.com |
Marion |
Linn |
Iowa |
Anna Walbridge |
Tyler Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Breonna Kay Nelson |
breanderson82@yahoo.com |
Self |
Marion |
Linn |
Iowa |
Anna Walbridge |
Tyler Nelson |
Signed |
204 |
2020-07-15 11:21 |
Anonymous (not verified) |
63.152.54.222 |
Tim Duggan |
Limited Liability Company |
1405 1st St. SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Timothy M Duggan |
tdc.inc30@gmail.com |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy M Duggan |
tdc.inc30@gmail.com |
President |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
1056 |
2022-04-18 12:04 |
Anonymous (not verified) |
63.152.56.49 |
Milo’s Construction |
Limited Liability Company |
8 Erobi ln Iowa city IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Adriana Celis |
celisary0501@gmail.com |
Iowa city |
Johnson |
Iowa |
Arcelia Gómez |
Karina Beltrán |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Milo’s Construction |
celisary0501@gmail.com |
Owner |
Iowa city |
Johnson |
Iowa |
Arcelia Gómez |
Karina Beltrán |
Signed |
908 |
2022-02-09 15:06 |
Anonymous (not verified) |
63.152.66.183 |
Shear Texture |
Limited Liability Company |
1427 A Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
1071 |
2022-04-26 15:31 |
Anonymous (not verified) |
63.152.69.47 |
Black squirrel siding llc |
Limited Liability Company |
1512 n 1st Ave apt c203s coralville,ia52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-26 |
Jeremiah Petsche |
jpetsche44@gmail.com |
Coralville |
Johnson |
Iowa |
Jessica schimf |
Karl schimf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah petsche |
jpetsche44@gmail.com |
Myself |
Coralville |
Johnson |
Iowa |
Jessica schimf |
Karl schimf |
Signed |
127 |
2020-04-24 09:18 |
Anonymous (not verified) |
63.152.82.5 |
TD Auto Services LLC |
Limited Liability Company |
451 W Parker St Waterloo IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-27 |
Dakoda Sellers |
dakoda.d.sellers@gmail.com |
Waverly |
Bremer |
IA |
Jennie Roster |
Dustin Roster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakoda D Sellers |
dakoda.d.sellers@gmail.com |
Owner |
Waverly |
Bremer |
IA |
Jennie Roster |
Dustin Roster |
Signed |
1143 |
2022-06-06 15:48 |
Anonymous (not verified) |
63.152.93.184 |
Adaptability Plus |
Limited Liability Company |
904 W 4th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
Timothy Combs |
tcombshd@gmail.com |
Cedar Falls |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Combs |
tcombshd@gmail.com |
none |
Cedar Falls |
Black Hawk |
Iowa |
Mark Moser |
Teresa Tjaden |
Signed |
1144 |
2022-06-06 15:51 |
Anonymous (not verified) |
63.152.93.184 |
Mark Moser |
Limited Liability Company |
904 W 4th St., Waterloo Iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
Mark Moser |
mpmmoser@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Moser |
mpmmoser@gmail.com |
none |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
1336 |
2022-10-17 12:42 |
Anonymous (not verified) |
63.152.97.11 |
Adaptability Plus Llc |
Limited Liability Company |
904 W 4th Street, Waterloo Iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-17 |
Timothy Combs |
timcombs@afiliowa.org |
Waterloo |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Combs |
timcombs@afiliowa.org |
none |
Waterloo |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
807 |
2021-12-20 09:30 |
Anonymous (not verified) |
63.153.145.38 |
Jerry Ollerich Trucking |
Proprietorship |
46884 267th Street Sioux Falls SD 57106 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-20 |
Jerald William Ollerich |
jeanollerich@yahoo.com |
Sioux Falls |
Minnehaha |
SD |
James K. Ollerich |
Joanne K. Berg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jean Staebell Ollerich |
jeanollerich@yahoo.com |
Wife/manager |
Sioux Falls |
Minnehaha |
SD |
James K. Ollerich |
Joanne K. Berg |
Signed |
1137 |
2022-06-01 09:05 |
Anonymous (not verified) |
63.170.122.111 |
sanchez framing construction llc |
Limited Liability Company |
113 e a 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. |
2022-06-01 |
Cindy Sanchez |
sanchezframingconst.llc@gmail.com |
west liberty |
muscatine |
iowa |
patricia verdines |
yajahira estrada |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
n/a |
sanchezframingconst.llc@gmail.com |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
Signed |
541 |
2021-06-15 07:04 |
Anonymous (not verified) |
63.224.181.101 |
Schultes Horticulture and Landscape LLC |
Limited Liability Company |
1444 42nd St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-15 |
Josh Schultes |
schulteshort@gmail.com |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Schultes |
schulteshort@gmail.com |
Self |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
365 |
2021-01-15 11:24 |
Anonymous (not verified) |
63.227.74.126 |
Paramount Kitchen and Bath |
Limited Liability Company |
2155 SE 37TH ST STE C |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-15 |
Michael Simpson |
mike@paramount-kitchens.com |
GRIMES |
Iowa |
United States |
Cory Morris |
Jason Andersen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Simpson |
mike@paramount-kitchens.com |
Owner |
GRIMES |
Iowa |
United States |
Cory Morris |
Jason Andersen |
Signed |
763 |
2021-11-22 12:32 |
Anonymous (not verified) |
63.229.189.35 |
Adam Dotson Tiling |
Proprietorship |
324 E 14th Street, 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. |
2021-11-22 |
Adam Dotson |
adamdotson1975@gmail.com |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Dotson |
adamdotson1975@gmail.com |
Self |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
765 |
2021-11-22 16:07 |
Anonymous (not verified) |
63.229.189.35 |
Stahmer Construction |
Proprietorship |
318 Jackson St N Harris IA 51345 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Alan Stahmer |
abigail@rickmilesartisans.com |
Harris |
Osceola |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alan Stahmer |
abigail@rickmilesartisans.com |
Self |
Harris |
Osceola |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
766 |
2021-11-22 16:19 |
Anonymous (not verified) |
63.229.189.35 |
Tribal Tile, LLC |
Limited Liability Company |
1402 Ithaca Ave, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Josh Loerzel |
joshloerzel@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Loerzel |
joshloerzel@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
IA |
Abigail Miles |
Alex Miles |
Signed |
767 |
2021-11-22 16:42 |
Anonymous (not verified) |
63.229.189.35 |
Lakes Custom Bath |
Proprietorship |
3721 Ithaca Avenue, Spirit Lake IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Rick Dykshoorn |
abigail@rickmilesartisans.com |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Dykshoorn |
abigail@rickmilesartisans.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
768 |
2021-11-22 16:53 |
Anonymous (not verified) |
63.229.189.35 |
Jeff Luchtel Painting |
Proprietorship |
PO Box 225, Milford, IA 51351-0225 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Jeff Luchtel |
jluchtel@gmail.com |
Milford |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Luchtel |
abigail@rickmilesartisans.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
769 |
2021-11-22 17:13 |
Anonymous (not verified) |
63.229.189.35 |
Jeff Johnson |
Proprietorship |
3114 Keokuk Ave, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Jeff Johnson |
juliejeff1994@yahoo.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Johnson |
abigail@rickmilesartisans.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
772 |
2021-11-23 10:13 |
Anonymous (not verified) |
63.229.189.35 |
Hubbards Cupboards |
Proprietorship |
713 2nd Ave SW, Spencer, IA 51301-5603 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-23 |
James Hubbard |
abigail@rickmilesartisans.com |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Hubbard |
abigail@rickmilesartisans.com |
Self |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
800 |
2021-12-15 16:50 |
Anonymous (not verified) |
63.229.189.35 |
CT Home Services |
Limited Liability Company |
706 Jackson Avenue, Spirit lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-15 |
Mike Oolman |
mikecthome@gmail.com |
Spirit lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Oolman |
mikecthome@gmail.com |
Self |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
869 |
2022-01-28 15:28 |
Anonymous (not verified) |
63.229.189.35 |
Jones Painting |
Proprietorship |
PO box 523, Okoboji, IA 51355 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-28 |
JD Jones |
abigail@rickmilesartisans.com |
Okoboji |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JD Jones |
abigail@rickmilesartisans.com |
Self |
Okoboji |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
870 |
2022-01-28 15:51 |
Anonymous (not verified) |
63.229.189.35 |
Cory Anderson |
Proprietorship |
2234 141st St, Fort Dodge, IA 50501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-28 |
Cory Anderson |
coryleeanderson@yahoo.com |
Fort Dodge |
Webster |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Anderson |
abigail@rickmilesartisans.com |
Self |
Fort Dodge |
Webster |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
1126 |
2022-05-25 12:06 |
Anonymous (not verified) |
63.229.189.35 |
Frame 2 Finish LLC |
Limited Liability Company |
25620 164th St Spirit lake, IA51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-05 |
Chris Miller |
frame2finish3550@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Miller |
frame2finish3550@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
1282 |
2022-08-25 06:51 |
Anonymous (not verified) |
63.240.136.241 |
River City Property Services LLC. |
Limited Liability Company |
1936 9th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-25 |
Brandon Smith |
RiverCityPropertyServices@outlook.com |
Camanche |
Iowa |
United States |
Sarah Smith |
MIke Burmahl |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Smith |
RiverCityPropertyServices@outlook.com |
Partner |
Camanche |
Iowa |
United States |
Sarah Smith |
MIke Burmahl |
Signed |
1059 |
2022-04-19 15:06 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILL GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
NICK HEATH |
dogboy3485@yahoo.com |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
1060 |
2022-04-19 15:08 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILLE GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
ADAM KELLY |
dslkraz@gmail.com |
CORRECTIONVILLE |
WOOD |
IWOA |
CANDACE |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
669 |
2021-10-13 08:24 |
Anonymous (not verified) |
64.191.11.62 |
E360 Building Company, Inc. |
Proprietorship |
PO Box 363, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-13 |
Mark Miller |
mark@e360buildingco.com |
Cedar Falls |
Black Hawk |
Iowa |
Laetyn Miller |
Grant Williamson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Miller |
markm@cfu.net |
Self |
Cedar Falls |
Black Hawk |
Iowa |
Laetyn Miller |
Grant Williamson |
Signed |
968 |
2022-03-11 15:39 |
Anonymous (not verified) |
64.191.6.226 |
Wedeking Custom Comfort LLC |
Limited Liability Company |
17541 Ridge Ave Clarksville, IA 50619 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-11 |
Justin Wedeking |
wedeking42@gmail.com |
Clarksville |
Butler |
Iowa |
Jason Grant |
Richard Grant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Wedeking |
wedeking42@gmail.com |
Self |
Clarksville |
butler |
Iowa |
Jason Grant |
Richard Grant |
Signed |
991 |
2022-03-21 15:25 |
Anonymous (not verified) |
64.191.6.226 |
Wheeler Painting |
Proprietorship |
102 Maple Circle Waverly Iowa 50677 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-21 |
Jon Wheeler |
jon.wheeler67@gmail.com |
Waverly |
Bremer |
Iowa |
Jason Grant |
Richard Grant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jon Wheeler |
jon.wheeler67@gmail.com |
Owner |
Waverly |
Bremer |
Iowa |
Jason Grant |
Richard Grant |
Signed |
1175 |
2022-07-05 07:56 |
Anonymous (not verified) |
64.251.168.116 |
Daniel Alan Valburg |
Proprietorship |
27656 SD Hwy 44 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Dan A Valburg |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvic |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Alan Valburg |
agflyer620@gwtc.net |
proprieter |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
1176 |
2022-07-05 08:08 |
Anonymous (not verified) |
64.251.168.116 |
Lucky Dude |
Proprietorship |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Lucky Dude |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucky Dude |
agflyer620@gwtc.net |
proprietor |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |