142 |
2020-04-28 10:16 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Timothy A Stoddard |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy A Stoddard |
chelsea.whalen@upperiowains.com |
Treasurer |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
114 |
2020-04-08 10:51 |
Anonymous (not verified) |
167.142.107.216 |
1959 |
Proprietorship |
601 Country Club Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-23 |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
SHELDON |
O'Brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
owner |
SHELDON |
O'brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
429 |
2021-03-10 12:52 |
Anonymous (not verified) |
173.23.50.65 |
Raleigh Electrical Services |
Limited Liability Company |
3747 SE 10th 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. |
2021-03-10 |
Timothy Bruce Raleigh |
tim@raleighelectrical.org |
Des Moines |
Polk |
Iowa |
Joe Coughlon |
Genna Prine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Bruce Raleigh |
tim@raleighelectrical.org |
Same |
Des Moines |
Polk |
Iowa |
Joe Coughlon |
Genna Prine |
Signed |
1143 |
2022-06-06 15:48 |
Anonymous (not verified) |
63.152.93.184 |
Adaptability Plus |
Limited Liability Company |
904 W 4th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
Timothy Combs |
tcombshd@gmail.com |
Cedar Falls |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Combs |
tcombshd@gmail.com |
none |
Cedar Falls |
Black Hawk |
Iowa |
Mark Moser |
Teresa Tjaden |
Signed |
1336 |
2022-10-17 12:42 |
Anonymous (not verified) |
63.152.97.11 |
Adaptability Plus Llc |
Limited Liability Company |
904 W 4th Street, Waterloo Iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-17 |
Timothy Combs |
timcombs@afiliowa.org |
Waterloo |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Combs |
timcombs@afiliowa.org |
none |
Waterloo |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
2044 |
2024-02-15 09:52 |
Anonymous (not verified) |
94.188.205.168 |
Messenger Trucking LLC |
Limited Liability Company |
1869 255th 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. |
2024-02-08 |
Timothy Duncan Messenger |
tmessengertrucking@gmail.com |
Fairfield |
Jefferson |
Iowa |
Casey Messenger |
Bud Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Duncan Messenger |
tmessengertrucking@gmail.com |
Self |
Fairfield |
Jefferson |
Iowa |
Casey Messenger |
Bud Smith |
Signed |
1588 |
2023-04-19 11:04 |
Anonymous (not verified) |
94.188.205.174 |
Peters Tree Service |
Proprietorship |
205 Melrose 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. |
2023-04-19 |
Timothy F Peters |
tim_peters1@hotmail.com |
Wall Lake |
Sac |
Iowa |
Bruce Paysen |
Roberta Paysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy F Peters |
tim_peters1@hotmail.com |
Self |
Wall Lake |
Sac |
Iowa |
Brace Paysen |
Roberta Paysen |
Signed |
2094 |
2024-03-14 10:16 |
Anonymous (not verified) |
94.188.207.225 |
Timothy Deutmeyer |
Proprietorship |
4014 iowa rd Center Point IA 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-14 |
Timothy Francis Deutmeyer |
timothydeutmeyer65@gmail.com |
Center Point |
Linn |
Iowa |
JAKE. Mcnurlaen |
Kevin Kinzebach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Francis Deutmeyer |
timothydeutmeyer65@gmail.com |
Owner |
CENTER POINT |
Linn |
Iowa |
Jake Mcnurlaen |
Kevin Kinzebach |
Signed |
204 |
2020-07-15 11:21 |
Anonymous (not verified) |
63.152.54.222 |
Tim Duggan |
Limited Liability Company |
1405 1st St. SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Timothy M Duggan |
tdc.inc30@gmail.com |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy M Duggan |
tdc.inc30@gmail.com |
President |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
947 |
2022-03-04 11:20 |
Anonymous (not verified) |
165.225.61.42 |
Timothy Peyton |
Proprietorship |
865 Bentley Dr Unit 23, Marion, IA, 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-04 |
Timothy Peyton |
theaton@amfam.com |
Marion |
Linn |
IA |
Terra Heaton |
Kari Benore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Peyton |
theaton@amfam.com |
self |
Marion |
Linn |
IA |
Terra Heaton |
Kari Benore |
Signed |
1062 |
2022-04-20 06:46 |
Anonymous (not verified) |
38.121.112.209 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Timothy Slobodnik |
cabinetsandclosetsbydesign@gmail.com |
Council Bluffs |
Pottawattamie |
IA |
Tom Pieper |
Jim Sietsema |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Slobodnik |
cabinetsandclosetsbydesign@gmail.com |
self |
Council Bluffs |
Pottawattamie |
IA |
Tom Pieper |
Jim Sietsema |
Signed |
1294 |
2022-09-04 18:09 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-04 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
1414 |
2023-01-07 22:14 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Proprietorship |
18409 250th Street, 430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-07 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
147 |
2020-05-02 09:07 |
Anonymous (not verified) |
75.162.65.142 |
Tim Soy |
Proprietorship |
3506 Amherst Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-01 |
Timothy Soy |
kingsoyboy@hotmail.com |
Des Moines |
Polk |
Iowa |
Aaron Page |
Jeremy Lukehart |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Soy |
kingsoyboy@hotmail.com |
Self |
Des Moines |
Polk |
Iowa |
Aaron page |
Jeremy Lukehart |
Signed |
2213 |
2024-05-08 13:37 |
Anonymous (not verified) |
94.188.205.174 |
Timothy strong |
Limited Liability Company |
615 61street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-08 |
Timothy Dewayne strong jr |
timothystrong33@gmail.com |
Davenport iowa |
USA |
Iowa |
Thomasina hunter |
Tyletha dates |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy strong painting |
timothystrong33@gmail.com |
Friend |
Davenport |
Usa |
Iowa |
Thomasina hunter |
Tyletha dates |
Signed |
1098 |
2022-05-12 17:54 |
Anonymous (not verified) |
199.66.15.123 |
Timothy W Robinson |
Proprietorship |
302 N Kenwood blvd Indianola IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-12 |
Timothy William Robinson |
williamswork18@gmail.com |
Indianola |
Warren |
Iowa |
Sarah Anne Robinson |
Andrew Gilbert Barber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy William Robinson |
williamswork18@gmail.com |
Sole proprietor |
Indianola |
Warren |
Iowa |
Sarah Anne Robinson |
Andrew Gilbert Barber |
Signed |
1117 |
2022-05-18 10:33 |
Anonymous (not verified) |
74.84.106.106 |
Tina Owens |
Proprietorship |
4162 Hwy F62 West Monroe, Iowa 50170 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-18 |
Tina M Owens |
towens974447@yahoo.com |
Monroe |
Jasper |
Iowa |
Ashley Owens |
Steve Wimer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tina Owens |
towens974447@yahoo.com |
self |
Monroe |
Jasper |
Iowa |
Ashley Ann Owens |
Steve Edwin Wimer |
Signed |
416 |
2021-03-02 10:33 |
Anonymous (not verified) |
173.31.147.225 |
TJ NAIG DBA NAIG CONSULTING |
Proprietorship |
PO BOX 678 ARNOLDS PARK IA 51331 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-25 |
TJADEN NAIG |
TJADENNAIG@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JOE LORING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TJADEN NAIG |
TJADENNAIG@GMAIL.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JOE LORING |
Signed |
1792 |
2023-08-08 20:19 |
Anonymous (not verified) |
94.188.207.229 |
Faith Based Construction |
Limited Liability Company |
6820 Holcomb Ave. Apt. 8 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-08 |
Toby Andrew Johns |
tobyjohns28@gmail.com |
URBANDALE |
Polk |
United States |
Melanie Jo Ayersman |
Emma Stover |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Toby Andrew Johns |
tobyjohns28@gmail.com |
self |
URBANDALE |
Polk |
United States |
Melanie Jo Ayersman |
Emma Stover |
Signed |
1780 |
2023-08-03 16:50 |
Anonymous (not verified) |
94.188.207.230 |
S-N-T BRINKMAN TRANSFER LLC |
Proprietorship |
401 East Dewey Street Cassville, WI 53806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-01 |
Todd A Brinkman |
sntbrink@hotmail.com |
Cassville |
Wisconsin |
Wisconsin |
Todd A Brinkman |
Todd A Brinkman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd A Brinkman |
sntbrink@hotmail.com |
Self employed |
Cassville |
Wisconsin |
Wisconsin |
Todd Brinkman |
Todd Brinkman |
Signed |
2150 |
2024-04-15 12:07 |
Anonymous (not verified) |
94.188.205.177 |
Todd E Holsteen |
Proprietorship |
16015 Hwy 99, Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-28 |
Todd E Holsteen |
kellylanz1967@gmail.com |
Burlington |
IL |
United States |
David Steele |
Kari Holsteen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd E Holsteen |
kellylanz1967@gmail.com |
Self |
Burlington |
IA |
United States |
David Steele |
Kari Holsteen |
Signed |
340 |
2020-12-18 08:37 |
Anonymous (not verified) |
172.83.31.129 |
Todd Fisher DBA Lake Country Window Cleaning |
Proprietorship |
1506 Willow Place, Clear Lake, IA 50428 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-12-18 |
Todd Fisher |
Lakecountrywindow@yahoo.com |
Clear Lake |
Cerro Gordo |
Iowa |
Matt Koch |
Deb Koch |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Todd Fisher |
lakecountrywindow@yahoo.com |
Same |
Clear Lake |
Cerro Gordo |
Iowa |
Matt Koch |
Deb Koch |
Signed |
381 |
2021-02-02 12:46 |
Anonymous (not verified) |
167.142.150.21 |
T and A Transfer, LLC. |
Limited Liability Company |
3330 340th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-02 |
Todd L Ahrenholtz |
todd.ahrenholtz123@gmail.com |
Manilla |
IA |
IA |
Angela Ahrenholtz |
Angela Ahrenholtz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd L Ahrenholtz |
todd.ahrenholtz123@gmail.com |
owner |
Manilla |
Iowa |
Iowa |
Angela Ahrenholtz |
Angela Ahrenholtz |
Signed |
1365 |
2022-11-09 15:42 |
Anonymous (not verified) |
173.189.165.11 |
Todd Nelson DBA: TSTR Custom Woodworking |
Proprietorship |
625 West Sovers St, Solon, IA 52333 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-09 |
Todd Nelson |
tstr4040@gmail.com |
Solon |
Johnson |
Iowa |
Jeff Bair-Agent |
Ryan Hajek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Nelson |
tstr4040@gmail.com |
Owner/Manager |
Solon |
Johnson |
IA |
Jeff Bair |
Ryan Hajek |
Signed |
539 |
2021-06-08 17:06 |
Anonymous (not verified) |
66.188.136.150 |
Todd Sechler |
Proprietorship |
505 5th Street Wellman, IA 52356 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-08 |
Todd Sechler |
kschumacher@tricorinsurance.com |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Sechler |
kschumacher@tricorinsurance.com |
Same |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
33 |
2020-01-09 15:57 |
Anonymous (not verified) |
173.28.28.57 |
FALCON PRIDE PROPERTIES LLC |
Limited Liability Company |
1401 HWY 57 PARKERSBURG, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-13 |
TODD THOMAS |
todd@wimcoach.com |
PARKERSBURG |
BUTLER |
IA |
CHAD CAMPBELL |
ROXANNE KOLDER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TODD THOMAS |
todd@wimcoach.com |
SELF |
PARKERSBURG |
BUTLER |
IA |
CHAD CAMPBELL |
ROXANNE KOLDER |
Signed |
1404 |
2023-01-03 15:26 |
Anonymous (not verified) |
173.20.50.85 |
Falcon Pride Properties, LLC |
Limited Liability Company |
1401 State Highway 57, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-23 |
Todd Thomas |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Thomas |
cmins_re@mchsi.com |
Owner |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1203 |
2022-07-13 09:49 |
Anonymous (not verified) |
69.57.16.37 |
Travis Trucking |
Proprietorship |
109 2ND ST, CURLEW, IA 50527 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-13 |
TODD TRAVIS |
toddthefarmet@gmail.com |
Curlew |
Palo Alto |
Iowa |
Alex Elbert |
Kelsey Elbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Travis |
toddthefarmet@gmail.com |
Owner/sole propietor |
Curlew |
Palo Alto |
Iowa |
Alex Elbert |
Kelsey Elbert |
Signed |
1240 |
2022-08-03 09:13 |
Anonymous (not verified) |
69.57.16.37 |
TRAVIS TRUCKING |
Proprietorship |
P.O BOX 54, CURLEW IOWA 50527 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-03 |
TODD TRAVIS |
TODDTHEFARMET@GMAIL.COM |
CURLEW |
PALO ALTO |
IOWA |
ALEX ELBERT |
KELSEY ELBERT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TODD TRAVIS |
TODDTHEFARMET@GMAIL.COM |
OWNER/SELF |
CURLEW |
PALO ALTO |
IOWA |
ALEX ELBERT |
KELSEY ELBERT |
Signed |
164 |
2020-05-26 10:30 |
Anonymous (not verified) |
166.182.80.35 |
T.W. Barton Restoration Service |
Proprietorship |
2704 Cass Avenue Mount Pleasant, Iowa 52641 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-26 |
Todd William Barton II |
twbartonrestoration@yahoo.com |
Mount Pleasant |
Henry |
Iowa |
Olivia Grace Barton |
Todd William Barton Sr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd William Barton II |
twbartonrestoration@yahoo.com |
Self |
Mount Pleasant |
Henry |
Iowa |
Olivia Grace Barton |
Todd William Barton Sr. |
Signed |
1591 |
2023-04-21 13:59 |
Anonymous (not verified) |
94.188.207.226 |
Self employed |
Proprietorship |
406 s main prairie city |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-21 |
Thomas Leo carroll |
Tom.carroll66@gmail.com |
Prairie city |
Jasper |
Iowa |
Tina hellyer |
Matt wenthie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tom carroll |
Tom.carroll66@gmail.com |
Self |
Prairie city |
Jasper |
Iowa |
Tina hellyer |
Matt whinthy |
Signed |
1270 |
2022-08-19 08:35 |
Anonymous (not verified) |
75.162.65.221 |
Tom Wilkinson |
Proprietorship |
621 Depot St, Kellogg, IA 50135 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-19 |
Tom Wilkinson |
tomwilkinson4588@yahoo.com |
Kellogg |
Jasper |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tom Wilkinson |
tomwilkinson4588@yahoo.com |
Self |
Kellogg |
Jasper |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1922 |
2023-11-24 14:29 |
Anonymous (not verified) |
94.188.207.226 |
Tommie Prince private contractor |
Proprietorship |
2320 Farwell Road, 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. |
2023-12-01 |
Tommie Prince |
amy@premierpayee.org |
Des Moines |
Polk |
Iowa |
Amy Meyer |
Morgan Meyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tomme Prince private contractor |
amy@premierpayee.org |
Self |
Des Moines |
Polk |
Iowa |
Amy Meyer |
Morgan Meyer |
Signed |
206 |
2020-07-16 08:18 |
Anonymous (not verified) |
97.64.194.122 |
Tommy Messino |
Proprietorship |
205 S Taylor St., Cherry, IL 61317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Tommy Messino |
kschumacher@tricorinsurance.com |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tommy Messino |
kschumacher@tricorinsurance.com |
Same |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
1697 |
2023-06-20 14:36 |
Anonymous (not verified) |
94.188.207.225 |
Quick Logistics LLC |
Limited Liability Company |
3817 Orleans Avenue, Sioux City, IA 51106 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-20 |
Tony J Moeller |
quick_logistics@outlook.com |
Sioux City |
IA |
United States |
Jordan Sitzmann |
Cody Stultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tony J Moeller |
quick_logistics@outlook.com |
Owner |
Sioux City |
IA |
United States |
Jordan Sitzmann |
Cody Stultz |
Signed |
435 |
2021-03-15 15:09 |
Anonymous (not verified) |
192.30.185.142 |
Marx Construction |
Proprietorship |
33044 484th Ave, Jefferson, SD 57038 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-15 |
Tony Marx |
tmarx416@hotmail.com |
Jefferson |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tony Marx |
tmarx416@hotmail.com |
Owner |
Jefferson |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
1528 |
2023-03-22 10:37 |
Anonymous (not verified) |
94.188.205.175 |
Uhl Cattle Company |
Partnership |
3329 Ozark Ave, Mapleton IA 51034 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Tonya Jean Uhl |
tonyajuhl@gmail.com |
Mapleton |
Woodbury |
iowa |
Keaten Anthony Miller |
Erik Michael Boyle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tonya Jean Uhl |
tonyajuhl@gmail.com |
Owner |
Mapleton |
Woodbury |
Iowa |
Keaten Anthony Miller |
Erik Michael Boyle |
Signed |
1529 |
2023-03-22 10:40 |
Anonymous (not verified) |
94.188.205.175 |
Uhl Cattle Company |
Partnership |
3329 Ozark Ave, Mapleton IA 51034 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Troy Michael Uhl |
troyuhl1224@gmail.com |
Mapleton |
Woodbury |
Iowa |
Keaten Anthony Miller |
Erik Michael Boyle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tonya Jean Uhl |
tonyajuhl@gmail.com |
Brother |
Mapleton |
Woodbury |
Iowa |
Keaten Anthony Miller |
Erik Michael Boyle |
Signed |
710 |
2021-11-04 12:57 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive Norwalk Iowa 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-04 |
Tory Webb |
torywebbdmi@gmail.com |
Norwalk |
Polk |
Iowa |
Ryan Drabek |
Dustin Kohler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Iowa |
United States |
Ryan Drabek |
Dustin Kohler |
Signed |
732 |
2021-11-09 15:25 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Ryan Drabek |
ryand@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Dustin Kohler |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Warren |
Iowa |
Trevor Spidle |
Dustin Kohler |
Signed |
733 |
2021-11-09 15:35 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Dustin Kohler |
dustink@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
torywebbdmi@gmail.com |
Owner, Management |
Norwalk |
Warren |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
1764 |
2023-07-27 09:56 |
Anonymous (not verified) |
94.188.207.224 |
Tracy Spray |
Proprietorship |
479 old lincoln hwy Mechanicsville 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. |
2023-07-27 |
Tracy spray |
tspray9@hotmail.com |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tracy Spray |
tspray9@hotmail.com |
Owner |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
495 |
2021-04-23 11:26 |
Anonymous (not verified) |
98.22.221.1 |
T & S Industries Inc |
Partnership |
200 West Jefferson |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-23 |
Tim Hunter |
tands@iowatelecom.net |
Afton |
IA |
IA |
Cindy R Harper |
Richard Mordock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travelers Insurance |
lisa@allplansins.com |
agent |
Afton |
IA |
IA |
Cindy R Harper |
Richard Mordock |
Signed |
472 |
2021-04-13 10:58 |
Anonymous (not verified) |
65.103.82.36 |
Scrap And More |
Proprietorship |
1303 W Linn St. Marshalltown, IA. 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-05-01 |
Travis Bachman |
na@yahoo.com |
marshalltown |
marshall |
IA |
sarah |
Tami |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Bachman |
na@yahoo.com |
owner |
marshalltown |
marsahll |
IA |
sara |
tami |
Signed |
1405 |
2023-01-04 11:56 |
Anonymous (not verified) |
67.55.135.18 |
Duncan Home Services LLC |
Limited Liability Company |
2543 Cottage Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-04 |
Travis Duncan |
projects@duncanhs.com |
Waverly |
IA |
United States |
Alethea Duncan |
Kristine Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Duncan |
projects@duncanhs.com |
self |
Waverly |
IA |
United States |
Alethea Duncan |
Kristine Fisher |
Signed |
1406 |
2023-01-04 11:58 |
Anonymous (not verified) |
67.55.135.18 |
Duncan Home Services LLC |
Limited Liability Company |
2543 Cottage Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-04 |
Alethea Anne Duncan |
projects@duncanhs.com |
Waverly |
IA |
United States |
Travis Duncan |
Kristine Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Duncan |
projects@duncanhs.com |
spouse |
Waverly |
IA |
United States |
Travis Duncan |
Kristine Fisher |
Signed |
1141 |
2022-06-03 08:15 |
Anonymous (not verified) |
173.23.251.188 |
SP Exteriors, LLC |
Limited Liability Company |
804 Philip St Des Moines, IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-03 |
Travis Espey |
tespey48@gmail.com |
Des Moines |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Espey |
tespey48@gmail.com |
owner |
Des Moines |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
9 |
2019-12-16 11:33 |
Anonymous (not verified) |
50.81.115.85 |
Travis Garrett and Caleb Elliott |
Partnership |
P.O. Box 55, Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-16 |
Travis Garrett |
onethird4599@gmail.com |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Garrett & Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
10 |
2019-12-16 11:35 |
Anonymous (not verified) |
50.81.115.85 |
Travis Garrett and Caleb Elliott |
Partnership |
P.O. Box 55, Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-16 |
Caleb Elliott |
onethird4599@gmail.com |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Garrett & Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
996 |
2022-03-22 23:37 |
Anonymous (not verified) |
173.27.235.109 |
patriot t services |
Proprietorship |
205 park st carlisle , ia 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-22 |
TRAVIS KEENEY |
knytrav@aol.com |
carlisle |
warren |
iowa |
james Ren |
Jesse Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Keeney |
knytrav@aol.com |
myself |
carlisle |
warren |
iowa |
james ren |
jesse parker |
Signed |