Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 1451 - 1500 of 2222. Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.

#	Submitted	User	IP address	Name of Employer:	Type of Entity:	Address of Employer's Home Office:	Statement 1 Agreement:	Statement 2 Agreement:	Statement 3 Agreement:	Understanding Confirmation:	Check Either Alternative (1) or (2):	Date:	Full Name of Individual:	Email:	City of Residence:	County of Residence:	State of Residence:	Full Name of Witness 1:	Full Name of Witness 2:	Signing Indication:	Check either alternative (1) or (2):	Full Name of Authorized Agent:	Email of Authorized Agent:	Relationship to Employer of Authorized Agent:	City of Residence:	County of Residence:	State of Residence:	Full Name of Witness No. 1:	Full Name of Witness No. 2:	Signing Indication:
1092	2022-05-09 17:49	Anonymous (not verified)	199.247.76.21	Mitchell Ellison	Limited Liability Company	906 Lakeshore Dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-09	Mitchell Ellison	Essential.ellison@gmail.com	Lakeside	Iowa	United States	Mitchell Ellison	Mitchell Ellison	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Ellison	Essential.ellison@gmail.com	Self	Lakeside	Iowa	United States	Mitchell Ellison	Mitchell Ellison	Signed
713	2021-11-05 10:41	Anonymous (not verified)	64.5.73.247	Mitchell Langel	Proprietorship	20581 300th St, Templeton IA 51463	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Mitchell Langel	gklangel@netins.net	Templeton	Carroll	Iowa	Jonathan Heydon	Lacey Marsh	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Langel	gklangel@netins.net	Owner	Templeton	Carroll	Iowa	Jonathan Heydon	Lacey Marsh	Signed
744	2021-11-11 15:22	Anonymous (not verified)	72.13.16.172	MJL TRANSPORT	Proprietorship	PO BOX 3301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-18	MJL TRANSPORT	dave@allseasonstrucking.com	DUBUQUE	DUBUQUE	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	MJL TRANSPORT	dave@allseasonstrucking.com	PRESIDENT	DUBUQUE	DUBUQUE	IA	Dave Neuwohner	BEN MOYER	Signed
491	2021-04-20 15:57	Anonymous (not verified)	199.102.210.217	mjm,inc	Proprietorship	32345 200th st dallas centert ia 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-20	john paul wewrner	johnpwerner17@gmail.com	osage	michell	ia	carolyn lee werner	amanda lee johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	johnwerner	johnpwerner17@gmail.com	friend	osage	mithell	ia	carolyn lee werner	amanda lee johnson	Signed
1632	2023-05-09 11:10	Anonymous (not verified)	94.188.205.177	MM Drywall LLC Moises Melo Santiago	Proprietorship	7500 Bloomfield Road Lot 78	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-01	Moises Melo Santiago	deb@piciowa.com	Des Moines	Polk	Iowa	kelly Denger	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	MM Drywall LLC Moises Melo Santiago	deb@piciowa.com	self	Des Moines	polk	Iowa	Kelly Denger	Debra Stratton	Signed
1514	2023-03-13 10:04	Anonymous (not verified)	94.188.205.166	MMK Electric	Limited Liability Partnership	4515 84th St 84th Street 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.	2023-03-13	Travis Miller	mmk.iowa@gmail.com	Urbandale	Polk	Iowa	Elijah Kain	Marshall McKay	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Elijah Kain	Marshall McKay	Signed
1520	2023-03-16 14:24	Anonymous (not verified)	94.188.205.167	MMK Electric	Partnership	4515 84th Street 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.	2023-03-16	Marshall Logan McKay	mmk.iowa@gmail.com	Des Moines	Polk	Iowa	Travis Miller	Elijah Kain	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Elijah Kain	Travis Miller	Signed
1521	2023-03-16 14:26	Anonymous (not verified)	94.188.207.229	Mmk electric	Partnership	4515 84th st Urbandale ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-16	Elijah dale kain	mmk.iowa@gmail.com	West Des moines	Polk	Iowa	Travis Lee miller	Marshall Logan McKay	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Lee miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Travis Lee miller	Marshall Logan mckay	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
668	2021-10-12 16:11	Anonymous (not verified)	173.18.22.217	Mo's Cleaning LLC	Limited Liability Company	1412 E 23rd St Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-12	Melissa Jones	commcleanwithme123@gmail.com	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Jones	commcleanwithme123@gmail.com	Owner	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed
1771	2023-08-01 09:59	Anonymous (not verified)	94.188.207.223	Modern Builder LLC	Limited Liability Company	30008 560th St Chariton IA 50049	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-01	Tatyana Sayenko	modernbuilder02@gmail.com	Chariton	Lucas	Iowa	Arthur Sayenko	Viktor Sayenko	Signed	(1) The employer does not elect the employers’ liability coverage.	Tatyana Sayenko	modernbuilder02@gmail.com	owner/ Family	Chariton	Lucas	Iowa	Arthur Sayenko	Viktor Sayenko	Signed
1027	2022-04-01 16:00	Anonymous (not verified)	75.162.62.199	Modern Carpentry Concepts	Limited Liability Company	2012 Ammann Dr. Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-01	Drew Hoffman	d.s.hoffman14@gmail.com	Adel	Dallas	Iowa	Jessica Hoffman	Warren Holder	Signed	(1) The employer does not elect the employers’ liability coverage.	Drew Hoffman	d.s.hoffman14@gmail.com	Same Person	Adel	Dallas	Iowa	Jessica Hoffman	Warren Holder	Signed
1018	2022-03-29 15:00	Anonymous (not verified)	97.125.143.50	Modified Originals of Winterset	Limited Liability Company	128 S 3rd Ave, Winterset, IA 50273	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Daniel Maiers	Modifiedoriginals.winterset@gmail.com	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Maiers	Modifiedoriginals.winterset@gmail.com	Self	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williamson	Signed
1481	2023-02-24 12:45	Anonymous (not verified)	94.188.207.223	Molly Onken	Limited Liability Company	52480 HWY 210 Slater, IA. 50244	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Molly S Onken	mollyaols@gmail.com	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed	(1) The employer does not elect the employers’ liability coverage.	Molly S Onken	mollyaols@gmail.com	Owner	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed
58	2020-02-10 21:18	Anonymous (not verified)	75.162.11.63	Moni tile Services llc	Limited Liability Company	2207 E Walnut St des Moines iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-01	Monica M Sandoval	Mjsandoval20@yahoo.com	Des Moines	Polk	United States	Cassie Ann bentz	James wesley harkert	Signed	(1) The employer does not elect the employers’ liability coverage.	Moni tile services llc	Mjsandoval20@yahoo.com	Self	Des Moines	Polk	Iowa	Cassie Ann bentz	James wesley harkert	Signed
69	2020-02-19 15:58	Anonymous (not verified)	198.14.241.59	MORENOS C ROOFING LLC	Limited Liability Company	2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed	(1) The employer does not elect the employers’ liability coverage.	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	OWNER	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed
1147	2022-06-08 11:29	Anonymous (not verified)	67.55.184.250	Morgan Anderson	Proprietorship	23379 120th Ave, Mediapolis, IA 52637	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-08	Morgan Duane Anderson	morgananderson6.ma@gmail.com	Mediapolis	IA	United States	Kelly S Lanz	Monte A Lanz	Signed	(1) The employer does not elect the employers’ liability coverage.	Morgan D. Anderson	morgananderson6.ma@gmail.com	sole proprietor	Mediapolis	Louisa	Iowa	Kelly Lanz	Monte Lanz	Signed
262	2020-09-18 13:54	Anonymous (not verified)	75.162.229.152	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-18	Mackinley Charles Morgan	MORGANGROUPLLC@GMAIL.COM	West Des Moines	Polk	Iowa	Mark Steven Morgan	Deborah Renee Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Mackinley Charles Morgan	MorganGroupLLC@gmail.com	Owner of Company	West Des Moines	Polk	Iowa	Mark Steven Morgan	Deborah Renee Morgan	Signed
640	2021-09-16 22:43	Anonymous (not verified)	97.125.255.204	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-16	Mackinley Charles Morgan	Morgangroupllc@gmail.com	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Mackinley Charles Morgan	Morgangroupllc@gmail.com	Owner of company	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed
846	2022-01-20 12:02	Anonymous (not verified)	97.107.199.129	Moval Motors LLC	Limited Liability Company	3153 Joliet Ave Missouri Valley IA 51555	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-19	Michael Porter	msporter8855@hotmail.com	Papillion	sarpy	Nebraska	Jon Paul Burton	Scott Porter	Signed	(1) The employer does not elect the employers’ liability coverage.	Micahel Porter	mporter8855@hotmail.com	secretary of Moval	Papillion	Sarpy	Nebraska	Jon Paul Bruton	Scott Porter	Signed
489	2021-04-20 13:47	Anonymous (not verified)	69.63.16.2	Mow-n-Mor Lawn & Landscaping LLC	Limited Liability Company	2585 500th St SW, Kalona, IA 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-19	Robert Sieren	mtesdell@yahoo.com	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Sieren	mtesdell@yahoo.com	Managing Member	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed
258	2020-09-15 13:14	Anonymous (not verified)	50.83.182.140	Moyer Painting	Proprietorship	934 Norwood Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	jerome Moyer	moyer_painting@live.com	Norwalk	IA	United States	Sally Moyer	Adam Adams	Signed	(1) The employer does not elect the employers’ liability coverage.	jerome b moyer	moyer_painting@live.com	Self	norwalk	IA	United States	sally moyer	Adam Adams	Signed
2126	2024-03-29 09:35	Anonymous (not verified)	94.188.207.227	MPO Masonry	Proprietorship	5027 s 20th at apt 12 Omaha ne 68107	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-29	Mauricio Ortega	pallaresmauricio72@gmail.com	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed	(1) The employer does not elect the employers’ liability coverage.	Mauricio Ortega	pallaresmauricio72@gmail.com	Self	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed
246	2020-08-25 15:36	Anonymous (not verified)	97.125.173.2	MPT plumbing	Limited Liability Company	4616 147th st 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.	2020-08-25	justin lee tigges	tplumbing3@aol.com	urbandale	dallas	iowa	insurance is a scam	I would get a different issurance company	Signed	(1) The employer does not elect the employers’ liability coverage.	grinnell mutual	lori@grinnellmutual.com	insurance agent	i dont know	I don't know	iowa	what a pain in the ass	This makes no sense	Signed
858	2022-01-27 08:06	Anonymous (not verified)	75.162.81.119	MR Custom Tile & Flooring LLC	Limited Liability Company	14390 Newbold Street, Indianola, IA, 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-27	Matthew Royer	royer20@yahoo.com	Indianola	Warren	United States	Leiloni Royer	Elena Royer	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Royer	royer20@yahoo.com	Myself	Indianola	Warren	United States	Leiloni Royer	Elena Royer	Signed
156	2020-05-13 20:37	Anonymous (not verified)	216.106.236.82	MR Electric LLC	Limited Liability Company	1853 230st Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-13	Matthew Rozeboom	matt.rozeboom@gmail.com	Inwood	Lyon	Iowa	Rachel Schruers	Caitlin Fluit	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Rozeboom	matt.rozeboom@gmail.com	Owner/President	Inwood	Lyon	Iowa	Rachel Schruers	Caitlin Fluit	Signed
1030	2022-04-05 06:27	Anonymous (not verified)	172.58.86.173	MR Roofing LLC	Limited Liability Company	8012 Ashridge Rd. Fort Worth, Tx 76134	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	MR Roofing LLC	mrroofing.pr@gmail.com	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Robledo	mrroofing.pr@gmail.com	Owner	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed
677	2021-10-18 11:09	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer 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.	2021-10-18	Marcie R Gaylord	avisburlington@hotmail.com	Fort Madison	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	Lee	Iowa	Kim Delap	Teri Coleman	Signed
678	2021-10-18 11:26	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer 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.	2021-10-18	Linda Hunter	whitandpayt@gmail.com	Burlington	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	IA	United States	Kim Delap	Teri Coleman	Signed
1293	2022-09-03 08:03	Anonymous (not verified)	50.82.244.98	MTZ Drywall	Proprietorship	1101 Eighth St, West Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-02	Richar Martinez	menace_42@icloud.com	West Des Moines	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Jenkins	jjenkins@farmersagent.com	N/A	Urbandale	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed
1856	2023-09-29 13:18	Anonymous (not verified)	94.188.205.166	MUESSIGMANN ENTERTAINMENT LLC	Limited Liability Company	906 2ND AVE SE 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.	2023-09-27	JON MUESSIGMANN	MUESSIGMANNENT@GMAIL.COM	SPENCER	CLAY	Iowa	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JON MUESSIGMANN	MUESSIGMANNENT@GMAIL.COM	SELF	SPENCER	CLAY	Iowa	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
670	2021-10-13 12:30	Anonymous (not verified)	173.19.179.111	MULLER TRANSPORT LLC	Limited Liability Company	2083 260TH ST MILFORD, IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-13	PAUL MULLER	MULLERTANSPORTLLC@GMAIL.COM	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	PAUL MULLER	JOEL@WALKERINSURANCEIA.COM	SELF	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
28	2020-01-06 13:39	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	NICOLAS MULLIS	JAMES@CIOIA.COM	GREELEY	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed	(1) The employer does not elect the employers’ liability coverage.	NICOLAS MULLIS	JAMES@CIOIA.COM	OWNER	GREELEY	DELAWARE	IA	MERRI MOSER	BRITTANY LANSING	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
779	2021-12-06 10:43	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue South	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-06	Douglas A Munn	munnent1328@gmail.com	Clear lake	IA	IA	Troy Thomas Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Munn	Troy@munnentllc.com	Owner	Clear Lake	Cerro Gordo	Iowa	Troy Thomas Munn	Marjorie Marie Munn	Signed
780	2021-12-06 10:45	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue South	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-06	Troy T Munn	Troy@munnentllc.con	Clear lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Thomas Munn	troy@munnentllc.com	Same	Clear Lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	Signed
1705	2023-06-23 16:01	Anonymous (not verified)	94.188.205.176	MV Carpentry LLC	Limited Liability Partnership	32724 U.S. 69 Huxley IA 50124	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-23	Carlos Moreno	Silencitopunk@gmail.com	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlos Moreno	silencitopunk@gmail.com	Husband	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed
1415	2023-01-09 10:50	Anonymous (not verified)	73.103.30.27	MWK Solutions, LLC	Limited Liability Company	1001 South Park St., Fairfield, IA 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-09	Michael Wayne Koch	mwkpar@gmail.com	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Wayne Koch	mwkpar@gmail.com	Self	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed
1199	2022-07-11 16:28	Anonymous (not verified)	166.222.225.181	Myriad Global Business Solutions	Proprietorship	8016 Brooks Loop	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-11	James Eugene Hasquet, III	Jay.Hasquet@Outlook.com	Spearfish	South Dakota	United States	Kent Orfield	Kyle Padget	Signed	(1) The employer does not elect the employers’ liability coverage.	James Eugene Hasquet, III	Jay.Hasquet@Outlook.com	Self	Spearfish	South Dakota	United States	Kent Orfield	Kyle Padget	Signed
1072	2022-04-26 16:17	Anonymous (not verified)	166.182.80.187	N & S Trucking Inc	Limited Liability Company	3061 170Th 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.	2022-04-26	Steven Kirk Van Ommen	Stevevo74@yahoo.com	Riverside	Iowa	United States	Steve Van Ommen	Steve Van Ommen	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Kirk Van Ommen	Stevevo74@yahoo.com	President	Riverside	IA	United States	Steve Van Ommen	Steve Van Ommen	Signed
1550	2023-03-31 13:35	Anonymous (not verified)	94.188.205.177	Nadarevic Group LLC	Limited Liability Company	3633 NW 177th Ct, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-31	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Owner	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed
1551	2023-03-31 13:37	Anonymous (not verified)	94.188.205.176	Nadarevic Group LLC	Limited Liability Company	3633 NW 177th Ct, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-31	Nicole Nadarevic	niki@silverstonedevgroup.com	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Owner	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed
265	2020-09-21 14:41	Anonymous (not verified)	74.84.65.174	Nagol Enterprises	Limited Liability Company	16124 PLEASANT VALLEY DR	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-21	Logan Victor Ante	antelogan@gmail.com	Story CIty	Story	iowa	Brian Wade Warren	Tyler Christian Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Logan Victor Ante	antelogan@gmail.com	Same	Story CIty	IA	IA	Brian Wade Warren	Tyler Christian Thompson	Signed
1758	2023-07-20 16:37	Anonymous (not verified)	94.188.205.174	Nailed It Remodeling Services LLC	Limited Liability Company	1520 Burnett Ave Ames, IA 50010	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-20	Kaylyn Christianson	kaylynchristianson@gmail.com	Ames	Story	Iowa	Jon Buller	Terry Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Kaylyn Christianson	KaylynChristianson@gmail.com	Manager	Ames	Story	Iowa	Jon Buller	Terry Miles	Signed
439	2021-03-18 08:09	Anonymous (not verified)	172.58.86.251	Nancy Lopez/Lifetime Roofing and Construction Corpn	Proprietorship	2234 Highland St 50315 Des Moines IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-18	Nancy Lopez/ Lifetime Roofing and Construction Corp	info@lifetimeroofingdsm.com	Des Moines	Polk	I A	Noe Ordaz	Fidel Rubio	Signed	(1) The employer does not elect the employers’ liability coverage.	Nancy Lopez	info@lifetimeroofingdsm.com	Owner	Des Moines	Polk	IA	Noe Ordaz	Fidel Rubio	Signed
956	2022-03-08 13:56	Anonymous (not verified)	72.13.16.196	Naprstek Media LLC	Limited Liability Company	6505 Wellington Ln, 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.	2022-03-08	James Naprstek	jimmy@kodiakcreative.com	Dubuque	Dubuque	Iowa	Trent Hanselmann	Jonathan O'Brien	Signed	(1) The employer does not elect the employers’ liability coverage.	Cheyenne Moseley	services@e.legazoom.com	Authorized Agent	Glendale	Los Angeles	CA	Trent Hanselmann	Jonathan O'Brien	Signed
1489	2023-02-28 16:06	Anonymous (not verified)	94.188.207.228	Nate's Tractor LLC	Limited Liability Company	11939 birch Ave Riceville, IA 50466	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-28	Nathan Fox	nate@natestractor.com	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Fox	nate@natestractor.com	Member	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed
506	2021-05-10 09:29	Anonymous (not verified)	199.102.211.129	Nathan J Hurst LLC DBA J&K Construction	Limited Liability Company	3598 Orchard Rd. Osage, IA 50461	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-10	Nathan J Hurst	jkconstructionjake@yahoo.com	Osage	Mitchell	Iowa	Breanna Fox	Karl Herman	Signed	(1) The employer does not elect the employers’ liability coverage.	Breanna Fox	jkconstructionjake@yahoo.com	Office Manager	Osage	Mithell	Iowa	Nathan J Hurst	Karl F Herman	Signed
1979	2024-01-08 14:59	Anonymous (not verified)	94.188.205.167	Nathan Troendle	Proprietorship	Lansing Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-05	Nathan Troendle	darrele@ciains.biz	Lansing	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Troendle	darrele@ciains.biz	self	Lansing	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed
248	2020-08-27 16:01	Anonymous (not verified)	142.202.101.194	Nathan Unruh Construction	Proprietorship	P.O. Box 181 Mechanicsville, IA. 52306	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-27	Nathan Unruh	Nathanunruh@gmail.com	Mechanicsville	Cedar	Iowa	Randy Rouse	Bruce Seehusen	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Unruh	nathanunruh@gmail.com	Same person	Mechanicsville	Cedar	Iowa	Randy Rouse	Bruce Seehusen	Signed

« first
‹ previous
…
26
27
28
29
30
31
32
33
34
…
next ›
last »