349 |
2020-12-31 17:37 |
Anonymous (not verified) |
107.77.161.33 |
JAG Painting |
Proprietorship |
1423 des moines 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. |
2020-12-31 |
Berenice Silva |
berenicesssvaldes@gmail.com |
Des moines |
Polk |
IA |
Manuel Aguilar |
Luis Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Berenice Silva |
berenicesssvaldes@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Manuel Aguilar |
Luis Garcia |
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 |
573 |
2021-07-14 09:12 |
Anonymous (not verified) |
166.181.83.201 |
Dustin Demoss |
Proprietorship |
407 mechanic st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-13 |
Dustin Michael DeMoss |
dustindemoss14@gmail.com |
Monmouth |
Iowa |
United States |
Jake |
Jake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Michael DeMoss |
dustindemoss14@gmail.com |
Idk |
Monmouth |
Iowa |
United States |
Jake |
Jake |
Signed |
685 |
2021-10-20 14:14 |
Anonymous (not verified) |
65.144.174.26 |
william c sawhill |
Proprietorship |
1625 Delaware Ave, Des Moines, 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-20 |
William C Sawhill |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
Iowa |
Nicholas W Sawhill |
Jenny M Steben |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William C Sawhill |
workorders@shoproyalflooring.com |
Self |
Des Moines |
Polk |
Iowa |
Nicholas W Sawhill |
Jenny M Steben |
Signed |
797 |
2021-12-15 08:01 |
Anonymous (not verified) |
173.22.84.26 |
LAMPE APPLIANCE SERVICE, Inc |
Proprietorship |
210 29TH 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. |
2021-12-15 |
Kenneth Roman Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Douglas James Lampe |
John Kenneth Lampe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
Vice President |
CEDAR RAPIDS |
Linn |
Iowa |
Douglas James Lampe |
John Kenneth Lampe |
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 |
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 |
1132 |
2022-05-28 12:01 |
Anonymous (not verified) |
166.181.81.175 |
Kamp Trucking LLC |
Limited Liability Company |
3411 doris 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. |
2022-05-28 |
Joseph Michael Kamp |
boss4z9@yahoo.com |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Michael Kamp |
boss4z9@yahoo.com |
same person. I am an owner operator |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
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 |
1835 |
2023-09-09 15:11 |
Anonymous (not verified) |
94.188.207.224 |
Heartland Ultrasonography Group |
Limited Liability Company |
1015 Woodland Dr Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-09 |
Micah Ezra Wiele |
mewiele99@gmail.com |
Ankeny |
Polk |
Iowa |
Nathan Miguel Diaz |
Brandon Allen Pemoulie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Micah Ezra Wiele |
heartlandusgroup@outlook.com |
Co-owner |
Ankeny |
Polk |
Iowa |
Nathan Miguel Diaz |
Brandon Allen Pemoulie |
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 |
29 |
2020-01-06 13:44 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
DAVID MULLIS |
JAMES@CIOIA.COM |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DAVID MULLIS |
JAMES@CIOIA.COM |
OWNER |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
1947 |
2023-12-07 16:01 |
Anonymous (not verified) |
94.188.205.176 |
Reinier Construction LLC |
Limited Liability Company |
1406 Linden 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. |
2023-12-07 |
David J Reinier |
reinierconst@aol.com |
Des Moines |
Polk |
IA |
PEGGY A ROHDE |
Douglas E Rohde |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PEGGY A ROHDE |
dnprohde@msn.com |
Bookkeeper |
Polk City |
Polk |
IA |
Douglas E Rohde |
Stacie L Miller |
Signed |
1468 |
2023-02-17 16:17 |
Anonymous (not verified) |
94.188.207.230 |
AJ Cook LLC |
Limited Liability Company |
1817 Redbud Street, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Alejandro Cook |
alejandro.cook14@gmail.com |
Norwalk |
Warren |
Iowa |
Steve Bieghler |
Nichole Bishop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alejandro Cook |
alejandro.cook14@gmail.com |
Self |
Norwalk |
Warren |
Iowa |
Steve Bieghler |
Nichole Bishop |
Signed |
141 |
2020-04-28 10:14 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-02 |
Steven Matter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Bobbi Jo Berg |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Matter |
chelsea.whalen@upperiowains.com |
Secretary |
Decorah |
Winneshiek |
IA |
BOBBI JO BERG |
Robin C Schultz |
Signed |
2059 |
2024-02-27 11:44 |
Anonymous (not verified) |
94.188.205.169 |
Dowdey Construction LLC |
Limited Liability Company |
1010 19th Ave - Rock Valley, IA 51247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-27 |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Self |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
1580 |
2023-04-17 20:22 |
Anonymous (not verified) |
94.188.205.167 |
Lance Van Der weerd |
Limited Liability Company |
909 S Adams Street Rock Rapids IA 51246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Rock Rapids |
IA |
United States |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Myself |
Rock Rapids |
Lyon |
Iowa |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
253 |
2020-09-09 12:27 |
Anonymous (not verified) |
173.18.16.129 |
H E Drywall INC |
Proprietorship |
200 E Lally 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. |
2020-09-09 |
Eriberto Castro |
hedrywall82@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
eriberto castro |
hedrywall82@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jake Hibbert |
Signed |
2171 |
2024-04-22 14:09 |
Anonymous (not verified) |
94.188.205.176 |
Messer's concrete cutting |
Proprietorship |
714 Summer 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. |
2024-04-22 |
Joe messer |
josephdmesser@gmail.com |
Burlington |
IA |
United States |
Joe messer |
Joe messer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joe messer |
josephdmesser@gmail.com |
Owner |
Burlington |
IA |
United States |
Joe messer |
Joe messer |
Signed |
1692 |
2023-06-15 15:20 |
Anonymous (not verified) |
94.188.207.228 |
Javier Rodriguez |
Proprietorship |
1512 18th St Des Moines, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-14 |
Javier A Rodriguez |
R.Javier14@gmail.com |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier A Rodriguez |
R.Javier14@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
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 |
477 |
2021-04-14 11:04 |
Anonymous (not verified) |
65.103.82.36 |
Lisa Kuhn |
Proprietorship |
427 s Concord 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. |
2020-01-09 |
Lisa Kuhn |
none@hotmail.com |
davenport |
Scott |
IA |
Sarah |
Erick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Kuhn |
none@hotmail.com |
self |
davenport |
scott |
IA |
sarah |
erick |
Signed |
589 |
2021-07-28 16:09 |
Anonymous (not verified) |
97.125.35.240 |
Sotero Alonso Calderon Velasquez |
Proprietorship |
1312 Idaho St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-26 |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
subcontractor |
Des MOines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
701 |
2021-10-29 18:35 |
Anonymous (not verified) |
173.18.85.215 |
Saunders Construction |
Proprietorship |
7304 SW 14th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-29 |
Charles Saunders |
charlessaunders901@gmail.com |
Des Moines |
Iowa |
Iowa |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Saunders |
charlessaunders901@gmail.com |
Owner |
Des Moines |
IA |
United States |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
813 |
2021-12-27 10:18 |
Anonymous (not verified) |
172.58.84.252 |
LLC |
Partnership |
866 40th Ave Bettendorf, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-23 |
Kimberly Anne Liggitt |
kliggitt25@gmail.com |
Rock Island |
IL |
United States |
Suzanne Jeanette Liggitt |
Christie Marie Liggitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
codydunbar@leaffilter.com |
Manager |
866 40th Ave Bettendorf ia 52722 |
Scott County |
IA |
Jordan nisiewicz |
Cody Dunbar |
Signed |
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 |
1036 |
2022-04-06 10:22 |
Anonymous (not verified) |
67.212.111.166 |
Precision Painting |
Proprietorship |
507 Broad Street, Reinbeck Iowa 50669 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-06 |
Dan Bowser |
dbowser.precision.painting@gmail.com |
Reinbeck |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
1148 |
2022-06-08 11:41 |
Anonymous (not verified) |
70.96.153.153 |
Brody Willet LLC |
Limited Liability Company |
244 #rd Ave N, Alburnett, IA 52202 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Brody Willet |
brody@optionsexteriors.com |
Alburnett |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brody Willet |
brody@optionsexteriors.com |
Owner |
Alburnett |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
1260 |
2022-08-16 11:30 |
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. |
2022-08-16 |
Jacob Dreifurst |
j_dreifurst@yahoo.com |
Colona |
Henry |
Illinois |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1851 |
2023-09-22 12:36 |
Anonymous (not verified) |
94.188.207.229 |
MNM Construction |
Proprietorship |
3224 sw 12th place des moines iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-22 |
craig allen mccormick |
craigmccormick.6363@gmail.com |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
craig mccormick |
craigmccormick.6363@gmail.com |
self |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
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 |
45 |
2020-01-28 16:13 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Adin Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lutfija Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
1963 |
2023-12-18 14:45 |
Anonymous (not verified) |
94.188.207.227 |
Elite Excavation Services |
Limited Liability Company |
13335 Amber Rd X44 Anamosa Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-18 |
Dalton Starn |
eliteexcavationservices97@gmail.com |
Anamosa |
Jones |
Iowa |
Chase miller |
Nathan Decker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Starn |
eliteexcavationservices97@gmail.com |
Owner |
Anamosa |
Jones |
Iowa |
Chase miller |
Nathan decker |
Signed |
1484 |
2023-02-25 16:42 |
Anonymous (not verified) |
94.188.205.177 |
Carpenter wood shed/ rays longging |
Limited Liability Company |
1631 230th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-27 |
Raymond Carpenter |
corinnafrymoyer@gmail.com |
tipton |
Cedar |
Iowa |
corinna frymoyer |
Levi carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Carpenter |
corinnafrymoyer@gmail.com |
Self |
Tipton |
Cedar |
Iowa |
Corinna frymoyer |
Levi carpenter |
Signed |
157 |
2020-05-14 15:11 |
Anonymous (not verified) |
173.28.28.57 |
Brett Dix |
Proprietorship |
16696 245th Street, Aplington, IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-30 |
Brett Dix |
cmins_re@mchsi.com |
Aplington |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brett Dix |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
2075 |
2024-03-05 22:32 |
Anonymous (not verified) |
94.188.207.225 |
Steve Roland Trucking LLC |
Limited Liability Company |
2141 Wadsley 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. |
2024-03-05 |
Steve Roland |
roland.farms@yahoo.com |
Sac City |
IA |
United States |
Caylee Hoffard |
Kristen Wirtjers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Roland |
roland.farms@yahoo.com |
Owner/Member |
Sac City |
IA |
United States |
Caylee Hoffard |
Kristen Wirtjers |
Signed |
1596 |
2023-04-24 15:48 |
Anonymous (not verified) |
94.188.205.174 |
Loyal Transport INC |
Proprietorship |
1987 Middle Calmar Road, Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-01 |
Lloyd Bjergum |
aryan1950@hotmail.com |
Decorah, IA |
Winneshiek |
Iowa |
Allen Monroe |
Amy Ryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lloyd Bjergum |
aryan1950@hotmail.com |
Self |
Decorah, |
Winneshiek |
Iowa |
Allen Monroe |
Amy Ryan |
Signed |
269 |
2020-09-23 09:18 |
Anonymous (not verified) |
76.76.239.60 |
belilove company of Iowa Inc |
Limited Liability Company |
601 south 23rd street Fairfield Iowa 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. |
2020-09-20 |
James Belilove |
jimb@cec-waterjet.com |
Fairfield |
Jefferson |
Iowa |
James thompson |
ellen bowen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Belilove |
jimb@cec-waterjet.com |
Owner and president |
Fairfield |
Jefferson |
Iowa |
James Thompson |
Ellen Bowen |
Signed |
2187 |
2024-04-29 08:30 |
Anonymous (not verified) |
94.188.207.226 |
Fran Stonework LLC |
Limited Liability Company |
1222 E Seneca Ave Apt 7, Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
1708 |
2023-06-25 15:10 |
Anonymous (not verified) |
94.188.207.228 |
Lopez concrete |
Limited Liability Company |
2009 otley ave 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. |
2023-06-25 |
Erick Lopez |
lopez1concrete@gmail.com |
Perry |
Dallas |
IA |
Ever tobar. |
Elba alejandro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erick lopez |
lopez1concreto@gmail.com |
Owner |
Perry |
Dallas |
IA |
Ever tobar |
Elba alejandro |
Signed |
381 |
2021-02-02 12:46 |
Anonymous (not verified) |
167.142.150.21 |
T and A Transfer, LLC. |
Limited Liability Company |
3330 340th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-02 |
Todd L Ahrenholtz |
todd.ahrenholtz123@gmail.com |
Manilla |
IA |
IA |
Angela Ahrenholtz |
Angela Ahrenholtz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd L Ahrenholtz |
todd.ahrenholtz123@gmail.com |
owner |
Manilla |
Iowa |
Iowa |
Angela Ahrenholtz |
Angela Ahrenholtz |
Signed |
493 |
2021-04-22 08:54 |
Anonymous (not verified) |
66.188.136.150 |
Frank Lantz |
Proprietorship |
609 Clinton Street, 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. |
2021-04-21 |
Frank Lentz |
kschumacher@tricorinsurance.com |
Charles City |
Floyd |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frank Lantz |
kschumacher@tricorinsurance.com |
Same |
Charles City |
Floyd |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
605 |
2021-08-16 16:06 |
Anonymous (not verified) |
67.55.155.46 |
COMPLETE CONSTRUCTION SERVICES LLC |
Limited Liability Company |
718 FOX RUN |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-16 |
DAVID BOWER |
BOWERD@OSKYCSD.ORG |
OSKALOOSA |
MAHASKA |
IOWA |
JAMES MCNAUL |
CINDY STEVENSON GRUBB |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DAVID BOWER |
BOWERD@OSKYCSD.ORG |
PRESIDENT |
OSKALOOSA |
MAHASKA |
IOWA |
JAMES MCNAUL |
CINDY STEVENSON GRUBB |
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 |
829 |
2022-01-11 11:03 |
Anonymous (not verified) |
173.22.78.156 |
Marr Arnold Planning, LLC |
Limited Liability Company |
1328 California Ave, Ames, IA 50014 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-11 |
Summer Marr |
summer@marrarnoldplanning.com |
Ames |
Story |
IA |
Beth Skluzacek |
Kris Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Summer Marr |
summer@marrarnoldplanning.com |
owner |
Ames |
Story |
IA |
Beth Skluzacek |
Kris Evans |
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 |
1052 |
2022-04-14 19:05 |
Anonymous (not verified) |
140.82.187.220 |
McHaddy Constuction |
Proprietorship |
423 Railroad St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Mick Haddeman |
mick@mchaddyconstruction.com |
Hudson |
Iowa |
United States |
Linsey Jo Haddeman |
Jordan Renae Haddeman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Haddeman |
mick@mchaddyconstruction.com |
self |
Hudson |
IA |
United States |
Linsey Jo Haddeman |
Jordan Renae Haddeman |
Signed |
1164 |
2022-06-23 09:26 |
Anonymous (not verified) |
74.84.106.106 |
Kimberly Owens |
Proprietorship |
2503 E 23rd street Newton, IA 50228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
Kimberly Owens |
kimmybobby1220@gmail.com |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Owens |
kimmybobby1220@gmail.com |
Self |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
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 |
1867 |
2023-10-16 12:34 |
Anonymous (not verified) |
94.188.205.176 |
North Bay Dock Service |
Proprietorship |
PO Box 374, 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. |
2023-10-16 |
Donald L. Johnson, Jr. |
djtjaj@outlook.com |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Teresa Johnson |
djtjaj@outlook.com |
bookkeeper |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |