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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# 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:
907 Anonymous (not verified) 173.28.0.37 Rusty K5 LLC Limited Liability Company 804 SW Cherry St Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-09 Kristy Briles kristyabriles@gmail.com Des Moines Polk IA Stephanie Seymour Sue Briles Signed (1) The employer does not elect the employers’ liability coverage. Kristy Briles kristyabriles@gmail.com Owner Des moines Polk IA 50313 Sue Briles Signed
1358 Anonymous (not verified) 172.86.32.251 LeafFilter North LLC Limited Liability Company 1020 James Drive Suite A | Hartland, WI 53209 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-03 Aaron Bensinger guttershereandnow@outlook.com Marion Linn Iowa Silvena Cammareri Aaron Bensinger Signed (1) The employer does not elect the employers’ liability coverage. Aaron Bensinger guttershereandnow@outlook.com Self Marion Linn Iowa Aaron Bensinger Silvena Cammareri Signed
1243 Anonymous (not verified) 173.24.221.228 Foreman's Tile Creations Proprietorship 1412 Franklin St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-04 Sole Proprietor fudog4man@gmail.com Center Point Linn IA Aaron Foreman Aaron Foreman Signed (1) The employer does not elect the employers’ liability coverage. Aaron Foreman fudog4man@gmail.com I am the Employer Center Point Linn IA Aaron Foreman Aaron Foreman Signed
147 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
692 Anonymous (not verified) 65.144.174.26 Jake Kenney Proprietorship 3201 Hillsdale Dr. , Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-26 Jacob Daniel Kenney Jakedkenney@hotmail.com Urbandale Polk Iowa Abbey Kenney Jory Ringler Signed (1) The employer does not elect the employers’ liability coverage. Jacob Daniel Kenney jakedkenney@hotmail.com Owner Urbandale polk ia abbey kenney jory ringler Signed
957 Anonymous (not verified) 71.39.227.238 Sharol Williams Proprietorship 1605 Ash St, Dallas Center, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-08 Sharol Williams sharolann48@gmail.com Dallas Center Dallas Iowa Abbey Luellen Steve Phillips Signed (1) The employer does not elect the employers’ liability coverage. Sharol Williams SharolAnn48@gmail.com Self Dallas Center Dallas Iowa Abbey Luellen Steve Phillips Signed
1327 Anonymous (not verified) 71.39.227.238 RICK OBEREMBT Proprietorship 1702 SYCAMORE ST, DALLAS CNETER, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-05 RICK OBEREMBT werock83@gmail.com DALLAS CENTER DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed (1) The employer does not elect the employers’ liability coverage. RICK OBEREMBT werock83@gmail.com SELF DALLAS CENTER DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed
1335 Anonymous (not verified) 71.39.227.238 PELZER AG LLC Limited Liability Company 16864 280TH ST, REDFIELD, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-17 MATT PELZER MPELZERFARMS@GMAIL.COM REDFIELD DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed (1) The employer does not elect the employers’ liability coverage. MATT PELZER MPELZERFARMS@GMAIL.COM PRESIDENT REDFIELD DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed
1422 Anonymous (not verified) 71.39.227.238 Udderly Great Downtown Scoops LLC Limited Liability Company 530 Walnut St, PO Box 251, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-09 Stephani S Jimmerson stephjimmerson67@gmail.com Minburn Dallas Iowa Abbey Luellen Laura Richardson Signed (1) The employer does not elect the employers’ liability coverage. Don Richardson DonR@phillipsassociatesins.net Agent Minburn Dallas Iowa Abbey Luellen Laura Richardson Signed
1923 Anonymous (not verified) 94.188.207.230 Chilled LLC Limited Liability Company 236 Meadow Breeze Ln 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. 2023-11-27 Lindsy J Trotter Lindsy@chilledfreezermeals.com Center Point Linn Iowa Abbie Snakenberg Amanda Guttau Signed (1) The employer does not elect the employers’ liability coverage. Lindsy Trotter Lindsy@chilledfreezermeals.com Owner Center Point Linn Iowa Abbie Snakenberg Amanda Guttau Signed
268 Anonymous (not verified) 174.217.16.178 Ayala Brothers Painting & Drywall Proprietorship 25089 H Ave Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-22 Edson Ayala Arizaga Ayalabrospainting@gmail.com Adel Dallas Iowa Abel Ayala Laura Orozco Signed (1) The employer does not elect the employers’ liability coverage. Edson Ayala Arizaga Edsonayala.12@gmail.com Owner Adel Dallas Iowa Abel Ayala Laura Orozco Signed
1959 Anonymous (not verified) 94.188.205.169 DeFreeceBuilt LLC Limited Liability Company 216 Rellim Dr Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-15 Dylan DeFreece dylan@defreecebuiltia.com Norwalk Warren Iowa Abigail DeFreece Ricki Schroeder Signed (1) The employer does not elect the employers’ liability coverage. Dylan DeFreece dylan@defreecebuiltia.com N/A Norwalk Warren Iowa Abigail DeFreece Ricki Schroeder Signed
763 Anonymous (not verified) 63.229.189.35 Adam Dotson Tiling Proprietorship 324 E 14th Street, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Adam Dotson adamdotson1975@gmail.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Adam Dotson adamdotson1975@gmail.com Self Spencer Clay Iowa Abigail Miles Alex Miles Signed
765 Anonymous (not verified) 63.229.189.35 Stahmer Construction Proprietorship 318 Jackson St N Harris IA 51345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Alan Stahmer abigail@rickmilesartisans.com Harris Osceola Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Alan Stahmer abigail@rickmilesartisans.com Self Harris Osceola Iowa Abigail Miles Alex Miles Signed
766 Anonymous (not verified) 63.229.189.35 Tribal Tile, LLC Limited Liability Company 1402 Ithaca Ave, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Josh Loerzel joshloerzel@gmail.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Josh Loerzel joshloerzel@gmail.com Self SPIRIT LAKE Dickinson IA Abigail Miles Alex Miles Signed
767 Anonymous (not verified) 63.229.189.35 Lakes Custom Bath Proprietorship 3721 Ithaca Avenue, Spirit Lake IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Rick Dykshoorn abigail@rickmilesartisans.com SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Rick Dykshoorn abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
768 Anonymous (not verified) 63.229.189.35 Jeff Luchtel Painting Proprietorship PO Box 225, Milford, IA 51351-0225 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Luchtel jluchtel@gmail.com Milford Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Luchtel abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
769 Anonymous (not verified) 63.229.189.35 Jeff Johnson Proprietorship 3114 Keokuk Ave, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Johnson juliejeff1994@yahoo.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Johnson abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
772 Anonymous (not verified) 63.229.189.35 Hubbards Cupboards Proprietorship 713 2nd Ave SW, Spencer, IA 51301-5603 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-23 James Hubbard abigail@rickmilesartisans.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. James Hubbard abigail@rickmilesartisans.com Self Spencer Clay Iowa Abigail Miles Alex Miles Signed
800 Anonymous (not verified) 63.229.189.35 CT Home Services Limited Liability Company 706 Jackson Avenue, Spirit lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-15 Mike Oolman mikecthome@gmail.com Spirit lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Mike Oolman mikecthome@gmail.com Self Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed
869 Anonymous (not verified) 63.229.189.35 Jones Painting Proprietorship PO box 523, Okoboji, IA 51355 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-28 JD Jones abigail@rickmilesartisans.com Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. JD Jones abigail@rickmilesartisans.com Self Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed
870 Anonymous (not verified) 63.229.189.35 Cory Anderson Proprietorship 2234 141st St, Fort Dodge, IA 50501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-28 Cory Anderson coryleeanderson@yahoo.com Fort Dodge Webster Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Cory Anderson abigail@rickmilesartisans.com Self Fort Dodge Webster Iowa Abigail Miles Alex Miles Signed
1126 Anonymous (not verified) 63.229.189.35 Frame 2 Finish LLC Limited Liability Company 25620 164th St Spirit lake, IA51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-05 Chris Miller frame2finish3550@gmail.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Chris Miller frame2finish3550@gmail.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
1885 Anonymous (not verified) 94.188.207.223 MB Radon Services Limited Liability Company 13206 State Hwy 2, Lamoni, Iowa, 50140 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-29 Kyle Ramaeker raymaker83@gmail.com LAMONI IA United States Adam Boge Lance Webster Signed (1) The employer does not elect the employers’ liability coverage. Kyle Ramaeker raymaker83@gmail.com Owner/Operator LAMONI IA United States Adam Boge Lance Webster Signed
2043 Anonymous (not verified) 94.188.207.226 mannys handyman services Limited Liability Company 3084 120th st cumming ia 50061 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-13 manuel v banegas mannyshandymanservices.ia@gmail.com cumming 3084 120th st iowa Adam Boge Lance Webster Signed (1) The employer does not elect the employers’ liability coverage. manuel v banegas mannyshandymanservices.ia@gmail.com self employeed Cumming Madison Iowa Adam Boge Lance Webster Signed
990 Anonymous (not verified) 174.192.80.32 Chris Binns Proprietorship 1324 Grand Ave Davenport, IA 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-21 Christ Binns christophersbinns@gmail.com Davenpory Scott IA Adam Coleman Rose Snyder Signed (1) The employer does not elect the employers’ liability coverage. Chris Binns christophersbinns@gmail.com Same Davenport Scott IA Adam Coleman Rose Snyder Signed
992 Anonymous (not verified) 174.192.66.11 Christopher Binns Proprietorship 1324 Grand Ave, Davenport, IA 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-21 Christopher Binns christophersbinns@gmail.com Davenport Scott IA Adam Coleman Rose Snyder Signed (1) The employer does not elect the employers’ liability coverage. Christopher Binns christophersbinns@gmail.com same Davenport Scott IA Adam Coleman Rose Snyder Signed
2015 Anonymous (not verified) 94.188.207.223 Salazar Builders inc Proprietorship 29175 365th st van meter 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. 2024-02-01 José Luis ángeles Salazar salazarbuilders15@gmail.com Van meter ia Dallas Iowa Adam Paul Boge Lance Owen Webster Signed (1) The employer does not elect the employers’ liability coverage. Jose Luis angeles Salazar salazarbuilders15@gmail.com Sub contractor Van meter Dallas Iowa Adam Paul Boge Lance Owen Webster Signed
1612 Anonymous (not verified) 94.188.207.223 Grind Works LLC Proprietorship 26416 289th place Unit H 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. 2023-04-27 Adam Samuelson Hello@grindworksia.com Adel Dallas Iowa Chandler Clark Adam Samuelson Signed (1) The employer does not elect the employers’ liability coverage. Adam Samuelson Hello@Grindowrksia.com N/A Adel Dallas Iowa Adam Samuelson Chandler Clark Signed
232 Anonymous (not verified) 173.27.57.39 Landeros & Sons Construction, Inc Limited Liability Partnership 1636 19th Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-16 Fernando Landeros fland1983@gmail.com Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed (1) The employer does not elect the employers’ liability coverage. Emanuel Landeros fland1983@gmail.com Brother Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed
522 Anonymous (not verified) 50.81.4.25 Crew Cut Lawn Care Limited Liability Company 7820 1st Ave NW Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-17 Rupert McKendly Ellis wideglide94@gmail.com Cedar Rapids Linn Iowa Adrian Pink Lorraine Ellis Signed (1) The employer does not elect the employers’ liability coverage. Rupert M Ellis wideglide94@gmail.com Owner Cedar Rapids Linn IA Adrian Pink Lorraine Signed
1905 Anonymous (not verified) 94.188.205.167 Bartolo Lopez Limited Liability Company 2404 cass st Fort Worth tx 76112 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-13 Bartolo Lopez bartololopez3737@gmail.com Fort Worth tx Tarrant county Tx Airan Zamudio Carlos Lopez Signed (1) The employer does not elect the employers’ liability coverage. Bartolo Lopez bartololopez3737@mail.com Boss of the company Fort Worth Tarrant county Texas Airan Zamudio Carlos lopez Signed
1897 Anonymous (not verified) 94.188.205.177 Matthew Jones Limited Liability Company 124 NE 49th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-06 Matthew Jones mjj4242@gmail.com Ankeny Polk IA Duan Willform AJ Giebelstein Signed (1) The employer does not elect the employers’ liability coverage. Matthew Jones mjj4242@gmail.com Self Ankeny Polk IA AJ Giebelstein Duan Willform Signed
1874 Anonymous (not verified) 94.188.205.166 Midwest UAV LLC Limited Liability Company 1400 15th St SE Bondurant Iowa 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-22 Kaleb Thomas Trammell kttrammell05@gmail.com Bondurant Polk IA Alan Willis Danielle Trammell Signed (1) The employer does not elect the employers’ liability coverage. Kaleb Thomas Trammell kttrammell05@gmail.com Owner Bondurant Polk IA Alan Willis Danielle Trammell Signed
508 Anonymous (not verified) 172.58.83.106 Aldo Monroy Limited Liability Company 201 Ne 44th St , Apt 111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Aldo Monroy Aldogmonroy@gmail.com Ankeny Polk IOWA Aldo Monroy Elizabeth lopez Signed (1) The employer does not elect the employers’ liability coverage. Aldo Monroy Aldogmonroy@gmail.com Owner Ankeny Polk IOWA Aldo g monroy reyes Elizabeth tavarez lopez Signed
448 Anonymous (not verified) 172.58.83.161 Limited Liability Company 201 Ne 44th St , Apt 111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-25 Aldo Monroy reyes Aldogmonroy@gmail.com Ankeny Polk county IOWA Elizabeth lopez Brayan monroy Signed (1) The employer does not elect the employers’ liability coverage. Aldo Monroy Aldogmonroy@gmail.com None Ankeny Polk county IOWA Aldo Monroy Brayan monroy Signed
1909 Anonymous (not verified) 94.188.207.228 CHAR-LES BUILDINGS LLC Limited Liability Company 14633 7TH AVE NW, ANDOVER MN 55304 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-15 JOHNNY CHAVEZ CHAVEZ charlychavez151@gmail.com ANDOVER ANOKA MINNESOTA ALEIDA LEE DANY JIMBO Signed (1) The employer does not elect the employers’ liability coverage. JOHNNY CHAVEZ CHAVEZ charlychavez151@gmail.com OWNER ANDOVER ANOKA MINNESOTA ALEIDA LEE DANY JIMBO Signed
1705 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
1293 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
1405 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
1203 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 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
242 Anonymous (not verified) 159.242.43.24 Bontreger Seamless Gutters Proprietorship 501 S Center St. Zearing Ia 50278 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Bontreger borntrgerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Bontreger borntrgerharvey@gmail.com Owner Zearing Story Ia Alex G Meier Daniel Wunschel Signed
243 Anonymous (not verified) 159.242.43.24 Borntreger Seamless Gutters Proprietorship 501 S Center St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Borntrager Borntregerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Borntreger borntregerharvey@gmail.com Owner Zearing Story Ia Alex Meier Daniel Wunschel Signed
302 Anonymous (not verified) 173.17.230.149 Absolute Construction Partnership 3720 Patricia Drive, 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. 2020-10-31 Joe Simpson jrsimpson27@gmail.com Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Joe Simpson jrsimpson27@gmail.com self Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed
1746 Anonymous (not verified) 94.188.205.176 Alex Webb Proprietorship 4019 West Roderweis Road Cabot Ar 72023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-14 Alex Webb frankie.webb@yahoo.com Cabot Pulaski Arkansas Mark Ellis Becky Ellis Signed (1) The employer does not elect the employers’ liability coverage. Ellis Flying Service INC. fly@ellisflying.com President Newport Arkansas United States Alex Webb Becky Ellis Signed
646 Anonymous (not verified) 173.24.107.209 QCA Professional Contractors Limited Liability Company 3314 67th Ave, Moline, IL. 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-20 Allan Celada allancelada@qcaprocontractors.com Moline Rock Island IL Alexander Celada Drexel Miller Signed (1) The employer does not elect the employers’ liability coverage. Allan Celada allancelada@qcaprocontractors.com self Moline Rock Island IL Alexander Celada Drexel Miller Signed
1044 Anonymous (not verified) 166.181.81.114 Paul Wall Assemblies LLC Limited Liability Company 38165 Belgian 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-04-13 Paul Carnicle paulcarnicle@yahoo.com Strawberry Point Iowa United States Alexander Gabriel Guthrie Sebastin Thompsin Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Paul Carnicle paulcarnicle@yahoo.com Partner Strawberry Point Iowa United States Alexander Gabriel Guthrie Sebastin Thompson Signed
1926 Anonymous (not verified) 94.188.207.224 M&M Janitorial LLC Limited Liability Company 243 28th St Dr SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-29 Mackenzie Willits mackenziewillits@gmail.com Cedar Rapids Linn United States Fransisco ruiz Alexander ruiz Signed (1) The employer does not elect the employers’ liability coverage. Meyling willits mackenziewillits@gmail.com Owner cedar rapids Linn United States Alexander ruiz Francisco ruiz Signed
1579 Anonymous (not verified) 94.188.205.177 Home provisions siding LLC Limited Liability Company 1816 Francis avenue apt 1 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-17 Luis Alberto Ramirez Mendez luisramirez4308@icloud.com Desmoines Polk Iowa Alexandra Gomez-Benitez Marcedez ramirez Signed (1) The employer does not elect the employers’ liability coverage. Luis Alberto Ramirez Mendez luisramirez4308@icloud.com None Des Moines Polk Iowa Alexandra Gomez-Benitez Marcedez Roxana Ramirez Signed