1181 |
2022-07-06 10:10 |
Anonymous (not verified) |
173.18.22.217 |
MB Masonry LLC |
Limited Liability Company |
PO Box 7534 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Owner |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
1193 |
2022-07-08 10:18 |
Anonymous (not verified) |
173.18.22.217 |
OWWT |
Limited Liability Company |
1915 SE Clovere Ridge Dr. 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. |
2022-07-08 |
Robert M Jackson |
dgfl08051982@gmail.com |
Ankeny |
Polk |
IA |
Lesa Reeves |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Jackson |
dgfl08051982@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Lesa Reeves |
Erick Sculdt |
Signed |
1205 |
2022-07-14 13:29 |
Anonymous (not verified) |
173.18.22.217 |
Residence Electric LLC |
Limited Liability Company |
5465 Mills Civic Pkwy #317 West Des Moines 50266 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-14 |
Anthony Rivera |
residenceelectric@outlook.com |
West Des Moines |
Polk |
Iowa |
Lesa Reeves |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Rivera |
residenceelectric@outlook.com |
Owner |
West Des Moines |
Polk |
Iowa |
Lesa Reeves |
Erick Schuldt |
Signed |
1208 |
2022-07-15 11:06 |
Anonymous (not verified) |
173.18.22.217 |
JL Elite Painting |
Limited Liability Company |
3416 NW 20th St 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. |
2022-07-15 |
Lizeth Benitez |
jl.elite.painting@gmail.com |
Ankeny |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lizeth Benitez |
jl.elite.painting@gmail.com |
owner |
Ankeny |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
1287 |
2022-08-30 13:11 |
Anonymous (not verified) |
173.18.22.217 |
Gomez Painting |
Limited Liability Company |
3609 56th St Des Moines IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Orlyn Gomez |
orlyngomez9@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Orlyn Gomez |
orlyngomez9@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
997 |
2022-03-23 06:15 |
Anonymous (not verified) |
167.142.233.235 |
Betsy Harms Agency LLC |
Limited Liability Company |
101 Sherman Ave, Ackley, IA 50601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Betsy Harms |
bharms@phillipsstafford.com |
Ackley |
Franklin |
IA |
Levi Harms |
Patricia Harms |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Betsy Harms |
bharms@phillipsstafford.com |
Self |
Ackley |
Franklin |
IA |
Levi Harms |
Patricia Harms |
Signed |
2078 |
2024-03-06 16:19 |
Anonymous (not verified) |
94.188.207.228 |
Iowa's Gutter Specialist LLC |
Limited Liability Company |
221 4th St SE Hampton Iowa 50441 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-06 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
Iowa |
United States |
Levi Paine |
Amy Hayes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
Iowa |
United States |
Levi Paine |
Amy Hayes |
Signed |
1487 |
2023-02-27 22:12 |
Anonymous (not verified) |
94.188.207.224 |
Panda garden |
Proprietorship |
105 2nd Ave se cresco ia 52136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Jing Chen |
jingchen9968@gmail.com |
Cresco |
Howard |
Iowa |
Leyang Zhou |
Guy Chen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jing Chen |
jingchen9968@gmail.com |
Self |
Cresco |
Howard |
Iowa |
Leyang zhou |
Guy Chen |
Signed |
1725 |
2023-07-07 13:37 |
Anonymous (not verified) |
94.188.205.167 |
Liana Fatino |
Limited Liability Company |
1930 se 14th des moines iowa 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. |
2023-07-07 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
USA |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
USA |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
1734 |
2023-07-11 08:25 |
Anonymous (not verified) |
94.188.207.226 |
LBN LLC |
Limited Liability Company |
1930 se 14th 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. |
2023-07-11 |
Liana Fatino |
lfatino@yahoo.com |
Des Moines |
Polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
owner |
des moines |
polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
1735 |
2023-07-11 08:28 |
Anonymous (not verified) |
94.188.207.229 |
LBN LLC |
Limited Liability Company |
1930 se 14th 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. |
2023-07-11 |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
Des Moines |
polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
owner |
des moines |
polk |
iowa |
liana fatino |
gary fatino |
Signed |
1736 |
2023-07-11 08:30 |
Anonymous (not verified) |
94.188.207.228 |
Scornos Waukee LLC |
Limited Liability Company |
286 w hickman rd 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. |
2023-07-11 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
owner |
des moines |
polk |
IOWA |
Liana Fatino |
Gary Fatino |
Signed |
1737 |
2023-07-11 08:32 |
Anonymous (not verified) |
94.188.207.223 |
Scornos waukee llc |
Limited Liability Company |
286 w hickman rd 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. |
2023-07-11 |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
owner |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
2104 |
2024-03-18 12:36 |
Anonymous (not verified) |
94.188.205.167 |
Scornoos 1973 INC |
Proprietorship |
8561 hickman rd 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. |
2024-03-18 |
Gary Fatino |
lfatino@yahoo.com |
des moines |
Polk |
iowa |
Liana Fatino |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
polk |
iowa |
Liana Fatino |
Lisa vacco |
Signed |
2106 |
2024-03-18 12:47 |
Anonymous (not verified) |
94.188.205.167 |
Scornos Altoona LLC |
Proprietorship |
2437 adventureland dr altoona iowaa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Gary Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
Liana Fatino |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
polk |
iowa |
Liana Fatino |
Lisa Vacco |
Signed |
1553 |
2023-04-04 14:52 |
Anonymous (not verified) |
94.188.205.177 |
TOPSOIL OUTDOOR SERVICES |
Limited Liability Company |
4919 SCHUBERT 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. |
2023-04-04 |
LIBAN |
topsoiloutdoor@gmail.com |
AMES |
IA |
United States |
Liban Wetzberger |
Liban Wertzberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liban Wertzberger |
topsoiloutdoor@gmail.com |
Owner |
AMES |
IA |
United States |
Liban Wertzberger |
Liban Wertzberger |
Signed |
504 |
2021-05-06 15:43 |
Anonymous (not verified) |
75.162.84.34 |
Erreguin Labra Roofing LLC |
Limited Liability Company |
642 S Washington Ave Mason City IA 50401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Hilario Labra Trejo |
erreguin06@gmail.com |
mason city |
cerro gordo |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Fernando Erreguin |
Erreguin06@gmail.com |
member |
Mason city |
cerro gordo |
iowa |
Liliana sanchez |
yolanda mendoza |
Signed |
1807 |
2023-08-17 12:45 |
Anonymous (not verified) |
94.188.205.175 |
LONE STAR ROOFING, LLC |
Limited Liability Company |
4021 WINDSOR CT 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. |
2023-08-17 |
RAQUEL B DIAZ MENENDEZ |
LONE.STAR.ROOFING76@GMAIL.COM |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LONE STAR ROOFING, LLC |
LONE.STAR.ROOFING76@GMAIL.COM |
MEMBER OWNER |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
2004 |
2024-01-28 12:41 |
Anonymous (not verified) |
94.188.205.174 |
Wasabi Urbandale LLC |
Limited Liability Company |
5106 155th Street, Urbandale, IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-28 |
Yean Ching Sue |
soamie@hotmail.com |
Urbandale |
Dallas |
Iowa |
Lina Zheng |
Jenna Yu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Yean Ching Sue |
soamie@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Lina Zheng |
Jenna Yu |
Signed |
1915 |
2023-11-21 04:06 |
Anonymous (not verified) |
94.188.207.225 |
Advanced Foam Systems |
Limited Liability Company |
1378 Midway Ave 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. |
2023-11-18 |
Randy Block |
advancedfoamsystems@yahoo.com |
Tripoli |
Bremer |
Iowa |
Linda Block |
Brady Block |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy Block |
advancedfoamsystems@yahoo.com |
Me |
Tripoli |
Bremer |
Iowa |
Linda block |
Brady block |
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 |
1747 |
2023-07-14 12:18 |
Anonymous (not verified) |
94.188.207.224 |
WIL-EQUIPMENT |
Limited Liability Company |
16400 Highway 92 Indianola Iowa 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-14 |
Brian Wilson |
wileq@outlook.com |
Indianola |
Warren |
Iowa |
Linda Jill Wilson |
Megan Elizabeth Wilson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Brian Wilson |
wileq@outlook.com |
Owner of Business |
Indianola |
Iowa |
United States |
Linda Jill Wilson |
Megan Elizabeth Wilson |
Signed |
1815 |
2023-08-23 14:16 |
Anonymous (not verified) |
94.188.207.228 |
JP Distribution, LLC |
Limited Liability Company |
3738 Pine Rdg 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. |
2023-08-23 |
Jared Prelle |
jpdist2014@gmail.com |
North Liberty |
IA |
United States |
Linda Stien |
Dawn Franck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Prelle |
jpdist2014@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Linda Stien |
Dawn Franck |
Signed |
2005 |
2024-01-29 08:50 |
Anonymous (not verified) |
94.188.207.226 |
Laser Line Striping |
Proprietorship |
10572 320th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-29 |
Dean Weikert |
d.lineuponline@yahoo.com |
Ackley |
Iowa |
United States |
Linda Weikert |
Ca |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kain Helmke |
d.lineuponline@yahoo.com |
D.lineuponline@yahoo.com |
Ackley |
Butler |
Iowa |
Linda Weikert |
Kain Helmke |
Signed |
778 |
2021-12-05 11:39 |
Anonymous (not verified) |
71.34.165.66 |
Perfection heating and Plumbing LLC |
Limited Liability Company |
2522 3 Ave 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. |
2021-12-05 |
Edward William cooper |
ecooper@amermech.com |
Altoona |
Polk |
IA |
Lindsay cooper |
Edward cooper SR |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eddie Cooper |
ecooper@amermech.com |
Self |
Altoona |
Polk |
IA |
Lindsay cooper |
Edward cooper SR |
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 |
1774 |
2023-08-03 08:40 |
Anonymous (not verified) |
94.188.205.168 |
J P Trucking, Inc. |
Proprietorship |
8768 White Tail Lane, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-03 |
Jamison Noel |
jptrucking.jamison@gmail.com |
Dubuque |
DBQ |
Iowa |
Lindsay Noel |
Andy Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamison Noel |
jptrucking.jamison@gmail.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Lindsay Noel |
Andy Kemp |
Signed |
1878 |
2023-10-26 09:06 |
Anonymous (not verified) |
94.188.205.168 |
Jones Facility Maintenance |
Limited Liability Company |
3929 Council Street 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. |
2023-10-25 |
Mason Jones |
jonesmason546@gmail.com |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Bradley Jones |
jonesmason546@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
2170 |
2024-04-22 10:11 |
Anonymous (not verified) |
94.188.207.224 |
Joy Ride Transport |
Limited Liability Company |
3105 SE Miehe Drive, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ted Cochran |
ted@ridejoyride.com |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Cochran |
ted@ridejoyride.com |
Self |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
1797 |
2023-08-14 09:37 |
Anonymous (not verified) |
94.188.205.175 |
SCG |
Limited Liability Company |
307 Bridge St. Redfield, IA 50233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
David Dwight Willis |
d.dubbaits@yahoo.com |
Redfield |
Dallas |
Iowa |
Lindsey Willis |
Sam Samuelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ross Turner |
RTurner@holmesmurphy.com |
Agent |
Waukee |
Dallas |
Iowa |
Brain Paterson |
Brandon DeGroff |
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 |
580 |
2021-07-22 10:40 |
Anonymous (not verified) |
72.13.27.253 |
Gudenkauf Tiling & Excavating LLC |
Limited Liability Company |
1840 275th St Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Terry Thomas Gudenkauf |
tlgudenkauf@yousq.net |
Manchester |
Delaware |
IA |
Lisa Gudenkauf |
Brandon Mather |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Gudenkauf |
tlgudenkauf@yousq.net |
Owner |
MAnchester |
IA |
United States |
Lisa Gudenkauf |
Brandon Mather |
Signed |
1049 |
2022-04-14 14:29 |
Anonymous (not verified) |
72.13.27.253 |
Gudenkauf Underground llc |
Limited Liability Company |
1840 275th St Manchester Ia., 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Self |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
671 |
2021-10-13 15:00 |
Anonymous (not verified) |
173.23.180.179 |
Larry and Company Inc. |
Proprietorship |
7239 Osage Road, Waterloo, Iowa 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. |
2021-10-13 |
Larry Rust |
larryandcoinc@hotmail.com |
Waterloo |
Black Hawk |
Iowa |
Lisa Kay Buls |
Kevin Thomas Buls |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Larry Alan Rust |
larryandcoinc@hotmail.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Lisa Kay Buls |
Kevin Thomas Buls |
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 |
1430 |
2023-01-25 14:50 |
Anonymous (not verified) |
104.222.82.50 |
Pille Ceramic Tile |
Proprietorship |
17645 Guthrie Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-25 |
Bernie Pille |
blpille@yahoo.com |
Maple River |
Carroll |
IA |
Lisa Pille |
None |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bernie Pille |
blpille@yahoo.com |
Self |
Maple River |
Carroll |
IA |
Lisa Pille |
Cameron Pille |
Signed |
1207 |
2022-07-15 10:02 |
Anonymous (not verified) |
75.89.78.50 |
A&J Remodeling LLC |
Limited Liability Company |
2 Bungalow Ct Newton, Iowa 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-15 |
Austin Hudson |
ahudson7536@gmail.com |
Newton |
Jasper |
IA |
Liz Allen |
Dustin Ingram |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Hudson |
anjremodel@gmail.com |
Co-owner |
Newton |
Jasper |
IA |
Liz Allen |
Dustin Ingram |
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 |
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 |
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 |
338 |
2020-12-13 16:31 |
Anonymous (not verified) |
107.77.161.48 |
LAVH LLC |
Limited Liability Company |
1520 E Pleasant View 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. |
2020-12-13 |
Luis Vasquez |
vasquezluis239@gmail.com |
Des Moines |
Polk |
Iowa |
Lorena Aguilar |
Carlos Mendoza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LAVH LLC |
vasquezluis239@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Lorena Aguilar |
Carlos Mendoza |
Signed |
842 |
2022-01-17 16:29 |
Anonymous (not verified) |
172.58.87.164 |
The Green Boys |
Limited Liability Company |
55 Southeast Windfield Parkway |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-17 |
Emilio Belismelis |
emiliobelismelis87@gmail.com |
Waukee |
IA |
United States |
Lorena Belismelis |
Lorena Belismelis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
The Green Boys |
emiliobelismelis87@gmail.com |
Owner |
Waukee |
IA |
United States |
Emilo Belismelis |
Maria Belismelis |
Signed |
98 |
2020-03-23 15:07 |
Anonymous (not verified) |
65.120.236.250 |
Cross Roads Logistics, LLC |
Limited Liability Company |
3103 21st 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 |
Mark Alan Cross |
rcreek2016@gmail.com |
Davenport |
IA |
IA |
Lori Ann Cross |
Barbara A Deering |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Alan Cross |
rcreek2016@gmail.com |
President/Owner |
Davenport |
IA |
IA |
Lori Ann Cross |
Barbara A Deering |
Signed |
1671 |
2023-06-01 11:17 |
Anonymous (not verified) |
94.188.205.166 |
Edwin Kime |
Proprietorship |
2920 Windsor av sumner 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. |
2023-06-01 |
edwin kime |
edwinkime01@gmail.com |
sumner |
ia |
United States |
Lori Ann kime |
Kiley Nicole kime |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
edwin kime |
edwinkime01@gmail.com |
Same |
sumner |
ia |
United States |
Lori Ann kime |
Kiley nicolevkime |
Signed |
511 |
2021-05-10 17:53 |
Anonymous (not verified) |
173.24.231.27 |
QSC Snow Removal |
Proprietorship |
1211 Carroll Boone IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Vincent A Kaylor |
phenox32@gmail.com |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vincent A Kaylor |
phenox32@gmail.com |
self |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
1549 |
2023-03-30 14:22 |
Anonymous (not verified) |
94.188.205.166 |
BILL MASSENGALE TRUCKING LLC |
Limited Liability Company |
4583 100TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-30 |
WILLIAM MASSENGALE |
BLMASSE31@GMAIL.COM |
MONTEZUMA |
Iowa |
United States |
Lori Massengale |
Brianna Massengale |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori MASSENGALE |
BLMASSE31@GMAIL.COM |
Spouse |
MONTEZUMA |
Iowa |
United States |
WILLIAM MASSENGALE |
Brianna MASSENGALE |
Signed |
2145 |
2024-04-11 12:27 |
Anonymous (not verified) |
94.188.205.177 |
Grinnell Web Services LLC |
Limited Liability Company |
1902 Spring St, Grinnell IA 50112 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-11 |
Richard Ethington |
RDE326@rrmse.com |
Grinnell |
Poweshiek |
Iowa |
Lori Stratton |
Lisa Folkmann |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Ethington |
rde326@rrmse.com |
self |
Grinnell |
poweshiek |
iowa |
lori stratton |
lisa folkmann |
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 |
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 |
1541 |
2023-03-29 11:21 |
Anonymous (not verified) |
94.188.205.174 |
Juilfs Trucking |
Proprietorship |
709 S Geneva St., P.O. Box 252 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-29 |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Pomeroy |
IA |
United States |
Lorie Gerdes |
Kerstin Lyon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Myself |
Pomeroy |
IA |
United States |
Lorie Gerdes |
Kerstin Lyon |
Signed |