780 |
2021-12-06 10:45 |
Anonymous (not verified) |
172.83.21.144 |
Munn Enterprises LLC |
Limited Liability Company |
118 14th Avenue South |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-06 |
Troy T Munn |
Troy@munnentllc.con |
Clear lake |
Cerro Gordo |
Iowa |
Douglas A Munn |
Marjorie Marie Munn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Thomas Munn |
troy@munnentllc.com |
Same |
Clear Lake |
Cerro Gordo |
Iowa |
Douglas A Munn |
Marjorie Marie Munn |
Signed |
527 |
2021-05-20 07:54 |
Anonymous (not verified) |
66.43.242.142 |
mcconnells custom construction |
Proprietorship |
1074 240th 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. |
2020-12-01 |
John McConnell |
jnkatmcc@netins.net |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
McConnell's Custom Construction |
jnkatmcc@netins.net |
owner |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
1595 |
2023-04-24 12:34 |
Anonymous (not verified) |
94.188.205.166 |
Ankeny & Neighbors |
Proprietorship |
603 South St, Cambridge Iowa 50046 |
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. |
2023-04-24 |
William Richard Borchard III |
william@damageddevicerepair.com |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Borchard III |
william@damageddevicerepair.com |
Sole proprietor/owner |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmore |
Signed |
655 |
2021-09-24 15:28 |
Anonymous (not verified) |
67.212.111.166 |
S Miller Painting LLC |
Limited Liability Company |
1135 Barnett Drive, Cedar Falls, Iowa 50613 |
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. |
2021-09-24 |
Steven David Miller |
stevendm24@hotmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Steve Koger |
Mark Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Allen koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk |
Iowa |
Steve Koger |
Mark Miller |
Signed |
2158 |
2024-04-17 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Mildred Lopez |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Mark Morrison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Mark Morrison |
Signed |
43 |
2020-01-27 09:23 |
Anonymous (not verified) |
71.199.85.251 |
ATW Training |
Limited Liability Company |
4414 114th Street, Urbandale Iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-25 |
Heather Hampton Cooper |
hcooper1@comcast.net |
Saint Augustine |
Saint Johns |
Florida |
Terry Lee Cooper |
Stacy Thatcher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lynn Roberts |
Lynne@atwtraining.com |
HR |
Des Moines |
Polk |
Iowa |
Cathy Belmont |
Mark Purcell |
Signed |
640 |
2021-09-16 22:43 |
Anonymous (not verified) |
97.125.255.204 |
Morgan Group LLC |
Limited Liability Company |
1124 7th St. West Des Moines, Iowa 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-16 |
Mackinley Charles Morgan |
Morgangroupllc@gmail.com |
West Des Moines |
Polk |
Iowa |
Deborah Renee Morgan |
Mark Steven Morgan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mackinley Charles Morgan |
Morgangroupllc@gmail.com |
Owner of company |
West Des Moines |
Polk |
Iowa |
Deborah Renee Morgan |
Mark Steven Morgan |
Signed |
874 |
2022-01-30 19:13 |
Anonymous (not verified) |
199.168.106.132 |
Pete Wilcox Trenching |
Proprietorship |
714 Main Street Cedar Falls IA 50613 |
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. |
2022-01-29 |
Peter Wilcox |
kwilcox@cfu.net |
Cedar Falls |
Black Hawk |
Iowa |
Terri Strein |
Marlene Rasmussen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
The Accel Group LLC |
info@acceladvantage.com |
customer |
Cedar Falls |
Black Hawk |
IA |
Terri Strein |
Marlene Rasmussen |
Signed |
1990 |
2024-01-16 22:22 |
Anonymous (not verified) |
94.188.205.168 |
DeltaPro Painting & Remodeling |
Limited Liability Company |
1115 Nolan Court North Liberty Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Bayron Amador |
bayronamador59@gmail.com |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bayron Amador |
bayronamador59@gmail.com |
Owner/Employer |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
960 |
2022-03-09 11:13 |
Anonymous (not verified) |
65.144.174.26 |
Jesus Munoz |
Proprietorship |
401 6th Ave Coralville, IA 52241 |
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. |
2022-03-09 |
Jesus Munoz |
jesus131805@gmail.com |
Coralville |
Johnson |
Iowa |
Juan Cruz |
Marlon Cruz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesus Munoz |
jesus131805@gmail.com |
Self |
Coralville |
Johnson |
Iowa |
Juan Cruz |
Marlon Cruz |
Signed |
319 |
2020-11-16 19:24 |
Anonymous (not verified) |
173.30.37.132 |
Nathan Wright |
Proprietorship |
500 2nd Avenue, Charles City, Iowa 50616 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-16 |
Nathan Robert Wright |
nrwright85@yahoo.com |
Charles City |
Floyd |
Iowa |
Jeff Wright |
Marsha Wright |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Robert Wright |
nrwright85@yahoo.com |
Self |
Charles City |
IA |
IA |
Jeff Wright |
Marsha Wright |
Signed |
1521 |
2023-03-16 14:26 |
Anonymous (not verified) |
94.188.207.229 |
Mmk electric |
Partnership |
4515 84th st Urbandale ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-16 |
Elijah dale kain |
mmk.iowa@gmail.com |
West Des moines |
Polk |
Iowa |
Travis Lee miller |
Marshall Logan McKay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Lee miller |
mmk.iowa@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Travis Lee miller |
Marshall Logan mckay |
Signed |
1514 |
2023-03-13 10:04 |
Anonymous (not verified) |
94.188.205.166 |
MMK Electric |
Limited Liability Partnership |
4515 84th St 84th Street Urbandale, Iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-13 |
Travis Miller |
mmk.iowa@gmail.com |
Urbandale |
Polk |
Iowa |
Elijah Kain |
Marshall McKay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Miller |
mmk.iowa@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Elijah Kain |
Marshall McKay |
Signed |
1155 |
2022-06-14 12:44 |
Anonymous (not verified) |
207.45.82.36 |
GREEN AND SHINE SERVICES INC |
Proprietorship |
210 Ne 41st st Apt 203 Ankeny, IA, 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-14 |
ALEX A. LOPEZ REDONDO |
greenandshineservices@gmail.com |
ankeny |
polk |
iowa |
Giselle roa |
Marta casado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex A Lopez Redondo |
greenandshineservices@gmail.com |
propery |
ankeny |
polk |
iowa |
Giselle Roa |
Marta Casado |
Signed |
1496 |
2023-03-06 11:24 |
Anonymous (not verified) |
94.188.207.227 |
Carrillo Drywall, LLC |
Limited Liability Company |
119 Marsh St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-06 |
Yesenia Carrillo |
yesecarrillo84@gmail.com |
Waterloo |
IA |
United States |
Rene Carrillo Jr |
Martha Basurto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Hildman |
kyleh@sinnottagency.com |
Insurance Agent |
Waterloo |
IA |
United States |
Rene Carrillo Jr |
Martha Basurto |
Signed |
872 |
2022-01-30 18:54 |
Anonymous (not verified) |
75.162.11.91 |
Iowa Carpentry Construction |
Limited Liability Company |
3000 University Ave #18105 West Des Moines,IA 50266 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-30 |
Carlos Velazquez |
jlctrimcarpenter@gmail.com |
Wes Des Moines |
Polk |
Iowa |
Carlos Velazquez |
Martha Marca |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Iowa Carpentry Construcion |
iowacarpentryconstruction@gmail.com |
Worker |
West Des Moines |
Polk |
Iowa |
Carlos Velazquez |
Martha Marca |
Signed |
1197 |
2022-07-11 08:35 |
Anonymous (not verified) |
107.127.35.22 |
Leaf Filter |
Limited Liability Partnership |
3060 SE Grimes Blvd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-11 |
Jacqueline Martínez |
charamusca05erick@icloud.com |
West Des Moines |
United Stated |
Iowa |
Melvin Gomez |
Martín Martínez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaf Filter |
support@leafhome.com |
Sub contractor |
Grimes |
United States |
Iowa |
Melvin Gomez |
Martín Martínez |
Signed |
1461 |
2023-02-17 07:48 |
Anonymous (not verified) |
94.188.205.168 |
Great Blinds LLC |
Limited Liability Company |
5174 Parkridge Ave Pleasant Hill, IA 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Andrew Mohrfeld |
mohrfeldandy@yahoo.com |
Pleasant Hill |
Polk |
IA |
Andrew Mohrfeld |
Martin Mohrfeld |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
John Lovell |
Jon@jlovellco.com |
None |
Urbandale |
Polk |
IA |
Andrew Mohrfeld |
Martin Mohrfeld |
Signed |
261 |
2020-09-17 15:52 |
Anonymous (not verified) |
65.127.131.118 |
Jesus Adrian Martinez |
Proprietorship |
1517 Searle St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-17 |
Jesus Adrian Martinez |
adrianmartinezventura21@gmail.com |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesus Adrian Martinez |
adrianmarinezventura21@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Martin Pinon |
Signed |
589 |
2021-07-28 16:09 |
Anonymous (not verified) |
97.125.35.240 |
Sotero Alonso Calderon Velasquez |
Proprietorship |
1312 Idaho St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-26 |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
subcontractor |
Des MOines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
1286 |
2022-08-26 09:09 |
Anonymous (not verified) |
97.125.43.203 |
Daniel Lugo |
Proprietorship |
1217 Harold 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. |
2022-08-24 |
Daniel Lugo |
deb@piciowa.com |
Des Mpines |
Polk |
IA |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel LUgo |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
1862 |
2023-10-05 14:30 |
Anonymous (not verified) |
94.188.207.225 |
J trinidad Garcia Ferrer |
Proprietorship |
3722 SE 14th St Apt 9 Des Moines, Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-01 |
J Trinidad Garcia Ferrer |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
J trinidad Garcia Ferrer |
deb@piciowa.com |
self |
Des Moines |
Polk |
IOwa |
Deb Stratton |
Martin Pinon |
Signed |
1065 |
2022-04-21 16:26 |
Anonymous (not verified) |
172.58.84.198 |
Royal Flooring |
Limited Liability Company |
11801 Hickman Rd Urbandale Iowa 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-21 |
Alondra Canedo Orta |
alondracanedo34@gmail.com |
Des Moines |
Polk county |
Iowa |
Alondra Canedo |
Marvin Bonilla |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Royal Flooring |
Workorders@shoproyalflooring.com |
Employee |
Des Moines |
Polk county |
Iowa |
Alondra Canedo |
Marvin Bonilla |
Signed |
1191 |
2022-07-07 12:15 |
Anonymous (not verified) |
207.177.48.254 |
Day Ag Service LLC |
Proprietorship |
28250 240th Street 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. |
2022-07-07 |
Calvin Brewer Day |
cal.d.day@gmail.com |
Dallas Center |
Dallas |
IA |
Dale Day |
Mary Beth Day |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Calvin Brewer Day |
cal.b.day@gmail.com |
Self |
Dallas Center |
Dallas |
IA |
Dale Day |
Mary Beth Day |
Signed |
102 |
2020-03-25 11:23 |
Anonymous (not verified) |
206.72.14.249 |
Brandi Wehr |
Proprietorship |
123 E Marion St, Sigourney, IA 52591 |
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. |
2020-03-25 |
Brandi Jo Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chelsea Voss |
chelsea@grimmrealestate.com |
Agent |
North English |
Iowa |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
606 |
2021-08-17 12:25 |
Anonymous (not verified) |
69.57.199.231 |
Precision Painting |
Proprietorship |
507 Broad 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-08-17 |
Daniel Paul Bowser |
danshonda12@gmail.com |
Reinbeck |
Grundy |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Sinnott Agency |
toms@sinnottagency.com |
Insurance provider |
Waterloo |
Blackhawk |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
607 |
2021-08-17 12:31 |
Anonymous (not verified) |
69.57.199.231 |
Precsion Painting |
Proprietorship |
507 Broad 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. |
2021-08-17 |
Daniel Paul Bowser |
danshonda12@gmail.com |
Reinbeck |
Grundy |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sinnott Agency |
toms@sinnottagency.com |
Insurance provider |
Waterloo |
Blackhawk |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
899 |
2022-02-05 13:35 |
Anonymous (not verified) |
67.3.142.168 |
Hart Holland LLC |
Limited Liability Company |
526 N 13th 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. |
2022-02-05 |
Elizabeth Holland |
ehollanddvm@gmail.com |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elizabeth Holland |
ehollanddvm@gmail.com |
self |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
900 |
2022-02-05 13:36 |
Anonymous (not verified) |
67.3.142.168 |
Iconic Properties LLC |
Limited Liability Company |
526 N 13th 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. |
2022-02-05 |
Elizabeth Holland |
ehollanddvm@gmail.com |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elizabeth Holland |
ehollanddvm@gmail.com |
self |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
1443 |
2023-02-07 10:05 |
Anonymous (not verified) |
166.181.84.211 |
Leaf home solutions |
Limited Liability Company |
1595 Georgetown rd Hudson Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-07 |
Dean Martells |
dn.mardesconstruction@gmail.com |
Laporte city |
Benton |
Ia |
Jeromia wilson |
Todd mcknees |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Yurko |
byurko@leacome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Brian mako |
Mat kaulig |
Signed |
133 |
2020-04-27 21:56 |
Anonymous (not verified) |
67.55.230.152 |
Hawkeye Carpentry LLC |
Limited Liability Company |
665 Penn Ridge Drive North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Travis Jaquay |
tjaquay@hotmail.com |
North Liberty |
Johnson |
Iowa |
Amber Butera |
Matt Butera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Compass Commercial Services |
Bshanahan@compass-built.com |
subcontractor |
Hiawatha |
Linn |
Iowa |
Amber Butera |
Matt Butera |
Signed |
1463 |
2023-02-17 14:24 |
Anonymous (not verified) |
94.188.207.224 |
Matt Evans |
Limited Liability Company |
508 53rd Place West Des Moines, IA 50266 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Matthew Evans |
matt@bigroofing515.com |
West Des Moines |
Polk |
Iowa |
Steve Bieghler |
Matt Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Evans |
matt@bigroofing515.com |
Self |
West Des Moines |
Polk |
Iowa |
Steve Bieghler |
Matt Evans |
Signed |
827 |
2022-01-10 16:36 |
Anonymous (not verified) |
167.142.141.89 |
Hill Lawn Care |
Proprietorship |
2307 Campbell Dr Marshalltown Iowa 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. |
2022-01-10 |
Raymond Hill |
rayhill_19@hotmail.com |
Marshalltown |
Marshall |
Iowa |
Kaitlyn Schuring |
Matt Gannaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Hill |
rayhill_19@hotmail.com |
Self |
Marshalltown |
Marshall |
Iowa |
Kaitlyn Schuring |
Matt Gannaway |
Signed |
1436 |
2023-02-01 11:53 |
Anonymous (not verified) |
174.215.242.112 |
Leaf home solutions |
Limited Liability Company |
1595 Georgetown Rd. Hudson, Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-01 |
Edward Koch |
etkdbq@aol.com |
Waterloo |
IA |
United States |
Glenda mclarty |
Coen Koch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian yurko |
byurko@leafhome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Brian Mako |
Matt kaulig |
Signed |
1742 |
2023-07-12 12:43 |
Anonymous (not verified) |
94.188.207.228 |
Old Glory Home Improvements LLC |
Limited Liability Company |
117 E Church st, Panora, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-12 |
Laden Binjiman McDonald |
mcdonaldladen@gmail.com |
Waukee |
Dallas |
Iowa |
Tina McDonald |
Matt McDonald |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Northwest Registered Agent |
bmartin@frannet.com |
Employer |
Panora |
Guthrie |
Iowa |
Tina McDonald |
Matt McDonald |
Signed |
2121 |
2024-03-28 00:05 |
Anonymous (not verified) |
94.188.205.176 |
James bunting |
Limited Liability Company |
6213 ridgewood meadows LN NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-28 |
James bunting |
jbflooringtile@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Codee Marie |
Matt reynolds |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James bunting |
jbflooringtile@gmail.com |
Myself |
Cedar Rapids |
Linn |
Iowa |
Codee Marie |
Matt reynolds |
Signed |
853 |
2022-01-24 08:45 |
Anonymous (not verified) |
173.27.193.218 |
Matt ruble |
Limited Liability Company |
808 Grandview ave Des Moines Iowa 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-23 |
Matthew ruble |
gmddetailing2012@gmail.com |
Des Moines |
Polk |
Iowa |
Matt Ruble |
Matt Ruble |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Ruble |
gmddetailing2012@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Matt Ruble |
Matt Ruble |
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 |
1348 |
2022-10-28 10:19 |
Anonymous (not verified) |
208.38.230.122 |
HALSEY'S HOME IMPROVEMENTS, LLC |
Limited Liability Company |
126 SYCAMORE LANE, RIVERDALE, IOWA 52722 |
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. |
2022-10-28 |
MONTY RAY HALSEY |
crickstic@gmail.com |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MONTY HALSEY |
crickstic@gmail.com |
SELF |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
1219 |
2022-07-21 12:39 |
Anonymous (not verified) |
98.22.2.115 |
Keeling Services |
Proprietorship |
3190 SE 64th St, pleasant Hill, IA 50327 |
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. |
2022-07-21 |
Josh keeling |
Joshuakeeling110@gmail.com |
Pleasant Hill |
Iowa |
United States |
Kali Keeling |
Matthew Keeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Bond |
mbond@leaffilter.com |
Regional sales manager |
Grimes |
Polk |
Iowa |
Kali Keeling |
Matthew Keeling |
Signed |
1542 |
2023-03-29 14:43 |
Anonymous (not verified) |
94.188.205.166 |
Peterson Home Improvement, LLC |
Limited Liability Company |
31451 510th Street Russell, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-28 |
Paul M Peterson |
petersonhomeimprovementllc@gmail.com |
Russell |
Lucas |
Iowa |
Peggy Jo Peterson |
Matthew Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peggy Peterson |
petersonhomeimprovementllc@gmail.com |
Husband |
Russell |
Lucas |
Iowa |
Paul M Peterson |
Matthew Peterson |
Signed |
2127 |
2024-03-29 09:50 |
Anonymous (not verified) |
94.188.205.177 |
Peterson Home Improvement, LLc |
Limited Liability Company |
31451 510th Street Russ |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-29 |
Paul M Peterson |
petersonhomeimprovementllc@gmail.com |
Russell |
Iowa |
Iowa |
Peggy Jo Peterson |
Matthew Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peggy Peterson |
petersonhomeimprovementllc@gmail.com |
Husband |
Russell |
Lucas |
Iowa |
Paul M Peterson |
Matthew Peterson |
Signed |
2190 |
2024-04-29 09:28 |
Anonymous (not verified) |
94.188.205.168 |
JOHNSON OHANA LLC |
Limited Liability Company |
145 GREENBRIER DR, 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. |
2024-04-29 |
JARED JOHNSON |
KONAOHANAICE@GMAIL.COM |
BURINGTON |
DES MOINES |
IOWA |
MARCY KNAUSS |
MATTHEW RINKER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAGGIE JOHNSON |
KONAOHANAICE@GMAIL.COM |
PARTNER/SPOUSE |
BURLINGTON |
DES MOINES |
IOWA |
MARCY KNAUSS |
MATTHEW RINKER |
Signed |
1587 |
2023-04-19 09:12 |
Anonymous (not verified) |
94.188.205.169 |
Sami Jo T Tappe |
Proprietorship |
7044 Carey Ct Johnston, IA 50131 |
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 |
Sami Jo Tappe |
samijotappe@gmail.com |
Johnston |
Polk |
Iowa |
Olga Sanchez |
Matthew Tappe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sami Jo Tappe |
samijotappe@gmail.com |
Self |
Johnston |
Polk |
Iowa |
Olga Sanchez |
Matthew Tappe |
Signed |
642 |
2021-09-17 11:09 |
Anonymous (not verified) |
167.142.95.56 |
Preferred Properties of Iowa, Inc. |
Limited Liability Company |
500 W. Temple 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. |
2021-09-17 |
Daniel Zech |
dan.ppi@gmail.com |
Lenox |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Zech |
dan.ppi@gmail.com |
Owner |
Lenox |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
643 |
2021-09-17 11:17 |
Anonymous (not verified) |
167.142.95.56 |
Preferred Properties of Iowa, Inc. |
Limited Liability Company |
500 W. Temple St., Lenox, IA 50851 |
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. |
2021-09-17 |
Mark Pearson |
mdpearson88@gmail.com |
Corning |
Adams |
Iowa |
Ron Travis |
Maury Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Zech |
dan.ppi@gmail.com |
Owner |
Lenox |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
644 |
2021-09-17 11:20 |
Anonymous (not verified) |
167.142.95.56 |
Preferred Properties of Iowa, Inc. |
Limited Liability Company |
500 W. Temple St., Lenox, IA 50851 |
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. |
2021-09-17 |
Brennan Kester |
mdpearson88@gmail.com |
Corning |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Zech |
dan.ppi@gmail.com |
owner |
Lenox |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
2020 |
2024-02-02 07:14 |
Anonymous (not verified) |
94.188.207.230 |
SM4 Consulting LLC |
Limited Liability Company |
503 E 6TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-02 |
Chad Smith |
sm4consultingllc@gmail.com |
PRAIRIE CITY |
Jasper |
Iowa |
Nicole Smith |
Maybelle Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Smith |
sm4consultingllc@gmail.com |
self |
PRAIRIE CITY |
Jasper |
Iowa |
Nicole Smith |
Maybelle Smith |
Signed |
1432 |
2023-01-25 16:52 |
Anonymous (not verified) |
174.228.33.48 |
Thermal Tight Insulators |
Proprietorship |
1331 Linden Road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-25 |
Shawn Carter |
steelershawn@gmail.com |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Carter |
steelershawn@gmail.com |
Self |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
1747 |
2023-07-14 12:18 |
Anonymous (not verified) |
94.188.207.224 |
WIL-EQUIPMENT |
Limited Liability Company |
16400 Highway 92 Indianola Iowa 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-14 |
Brian Wilson |
wileq@outlook.com |
Indianola |
Warren |
Iowa |
Linda Jill Wilson |
Megan Elizabeth Wilson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Brian Wilson |
wileq@outlook.com |
Owner of Business |
Indianola |
Iowa |
United States |
Linda Jill Wilson |
Megan Elizabeth Wilson |
Signed |