134 |
2020-04-28 08:15 |
Anonymous (not verified) |
66.188.136.150 |
Lowell Fenton |
Proprietorship |
404 1/2 W Main 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. |
2020-04-27 |
Lowell Fenton |
fentonlowell@gmail.com |
Decorah |
Winneshiek |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lowell Fenton |
kschumacher@tricorinsurance.com |
Same person |
Decorah |
Winneshiek |
IA |
Russell Masartis |
Shuree Behr |
Signed |
206 |
2020-07-16 08:18 |
Anonymous (not verified) |
97.64.194.122 |
Tommy Messino |
Proprietorship |
205 S Taylor St., Cherry, IL 61317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Tommy Messino |
kschumacher@tricorinsurance.com |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tommy Messino |
kschumacher@tricorinsurance.com |
Same |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
369 |
2021-01-22 10:02 |
Anonymous (not verified) |
66.188.136.150 |
Rick Swaney |
Proprietorship |
1551 Persimmon, Stilwell, OK 74960 |
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. |
2021-01-22 |
Rick Swaney |
kschumacher@tricorinsurance.com |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Swaney |
kschumacher@tricorinsurance.com |
Same |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
372 |
2021-01-25 08:38 |
Anonymous (not verified) |
66.188.136.150 |
Sawa Cheroke Transport, LLC |
Limited Liability Company |
PO Box 168, Stilwell, OK 74960 |
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. |
2021-01-25 |
Lisa Pritchett |
kschumacher@tricorinsurance.com |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sawa Cheroke Transport, LLC |
kschumacher@tricorinsurance.com |
Same |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
373 |
2021-01-25 09:06 |
Anonymous (not verified) |
66.188.136.150 |
Daniel Kulberg |
Proprietorship |
PO Box 641, Renville, MN 56284 |
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. |
2021-01-25 |
Daniel Kulberg |
kschumacher@tricorinsurance.com |
Renville |
Renville |
MN |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Kulberg |
kschumacher@tricorinsurance.com |
Same |
Reville |
Renville |
MN |
Russell Masartis |
Shuree Behr |
Signed |
375 |
2021-01-25 16:03 |
Anonymous (not verified) |
66.188.136.150 |
Logan Beauregard |
Proprietorship |
615 Oak Ave N, Onalaska, WI 54650 |
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. |
2021-01-25 |
Logan Beauregard |
kschumacher@tricorinsurance.com |
Onalaska |
La Crosse |
WI |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Logan Beauregard |
kschumacher@tricorinsurance.com |
Same |
Onalaska |
La Crosse |
WI |
Russell Masartis |
Shuree Behr |
Signed |
401 |
2021-02-15 14:50 |
Anonymous (not verified) |
66.188.136.150 |
Jarrod Wernimont |
Proprietorship |
24 Blackhawk Rd. Hanover, IL 61041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Jarrod Wernimont |
kschumacher@tricorinsurance.com |
Hanover |
Jo Daviess |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jarrod Wernimont |
kschumacher@tricorinsurance.com |
Same |
Hanover |
Jo Daviess |
IL |
Russell Masartis |
Shuree Behr |
Signed |
402 |
2021-02-15 16:33 |
Anonymous (not verified) |
66.188.136.150 |
K.C. Ansel |
Proprietorship |
101 Cherokee Dr. Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-15 |
K.C. Ansel |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
K.C. Ansel |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Shuree Behr |
Signed |
431 |
2021-03-10 14:41 |
Anonymous (not verified) |
66.188.136.150 |
Brad Donovan |
Proprietorship |
1105 N 5th. Springfield, IL 62702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
Brad Donovan |
braddonovan40@gmail.com |
Springfield |
Sangamon |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brad Donovan |
braddonovan40@gmail.com |
Same |
Springfield |
Sangamon |
IL |
Russell Masartis |
Shuree Behr |
Signed |
440 |
2021-03-18 08:11 |
Anonymous (not verified) |
66.188.136.150 |
Jeffrey Gardner |
Proprietorship |
3020 W 1st St., Davenport, IA 52804 |
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. |
2021-03-17 |
Jeffrey Gardner |
kschumacher@tricorinsurance.com |
Davenport |
Polk |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Gardner |
kschumacher@tricorinsurance.com |
Same |
Davenport |
Polk |
IA |
Russell Masartis |
Shuree Behr |
Signed |
450 |
2021-03-25 11:59 |
Anonymous (not verified) |
66.188.136.150 |
Mason Cook |
Proprietorship |
10604 Bradford Road, Indianapolis, IN 46231 |
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. |
2021-03-23 |
Mason Cook |
kschumacher@tricorinsurance.com |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Cook |
kschumacher@tricorinsurance.com |
Same |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
459 |
2021-04-05 14:24 |
Anonymous (not verified) |
66.188.136.150 |
Gerald Bosch |
Proprietorship |
14359 County Rd. G62 Wapello, IA 52653 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-02 |
Gerald Bosch |
kschumacher@tricorinsurance.com |
Wapello |
Louisa |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerald Bosch |
kschumacher@tricorinsurance.com |
Same |
Wapello |
Louisa |
IA |
Russell Masartis |
Shuree Behr |
Signed |
521 |
2021-05-17 14:23 |
Anonymous (not verified) |
66.188.136.150 |
Ron Wagner |
Proprietorship |
602 1/2 Ave G Apt. 5 Ft. Madison, IA 52627 |
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 |
Ron Wagner |
kschumacher@tricorinsurance.com |
Ft. Madison |
Lee |
IA |
Jordan Bass |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Wagner |
kschumacher@tricorinsurance.com |
Same |
Ft. Madison |
Lee |
IA |
Jordan Bass |
Shuree Behr |
Signed |
526 |
2021-05-19 09:36 |
Anonymous (not verified) |
66.188.136.150 |
John Robinson |
Proprietorship |
12990 E 48th Ave. Denver, CO 80239 |
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. |
2021-05-18 |
John Robinson |
kschumacher@tricorinsurance.com |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Robinson |
kschumacher@tricorinsurance.com |
Same |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
528 |
2021-05-21 14:06 |
Anonymous (not verified) |
66.188.136.150 |
Russell Masartis |
Proprietorship |
481 Clarendon East Dubuque, IL 61025 |
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. |
2021-05-21 |
Russell Masartis |
kschumacher@tricorinsurance.com |
East Dubuque |
Jo Daviess |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Russell Masartis |
kschumacher@tricorinsurance.com |
Same |
East Dubuque |
Jo Daviess |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
537 |
2021-06-07 15:25 |
Anonymous (not verified) |
66.188.136.150 |
Casey Young |
Proprietorship |
10731 State Highway 118 Turrell, AR 72384 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-03 |
Casey Young |
kschumacher@tricorinsurance.com |
Turrell |
Crittenden |
AR |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casey Young |
kschumacher@tricorinsurance.com |
Same |
Turrell |
Crittenden |
AR |
Mitch Kemp |
Shuree Behr |
Signed |
538 |
2021-06-08 16:59 |
Anonymous (not verified) |
66.188.136.150 |
John Sorrentino |
Proprietorship |
808 Dixie Dr. Enterprise, AL 36330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-08 |
John Sorrentino |
kschumacher@tricorinsurance.com |
Enterprise |
Coffee |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Sorrentino |
kschumacher@tricorinsurance.com |
Same |
Enterprise |
Coffee |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
539 |
2021-06-08 17:06 |
Anonymous (not verified) |
66.188.136.150 |
Todd Sechler |
Proprietorship |
505 5th Street Wellman, IA 52356 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-08 |
Todd Sechler |
kschumacher@tricorinsurance.com |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Sechler |
kschumacher@tricorinsurance.com |
Same |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
553 |
2021-07-01 08:17 |
Anonymous (not verified) |
66.188.136.150 |
Cody Belleville |
Proprietorship |
57167 Copperdate Dr. Elkhart, IN 46516 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-30 |
Cody Belleville |
kschumacher@tricorinsurance.com |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Belleville |
kschumacher@tricorinsurance.com |
Same |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
556 |
2021-07-07 09:16 |
Anonymous (not verified) |
66.188.136.150 |
William Campbell |
Proprietorship |
159 Friendly Blvd. Springfield, IL 62707 |
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. |
2021-07-06 |
William Campbell |
kschumacher@tricorinsurance.com |
Springfield |
Sangamon |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Campbell |
kschumacher@tricorinsurance.com |
Same |
Springfield |
Sangamon |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
557 |
2021-07-07 09:51 |
Anonymous (not verified) |
66.188.136.150 |
Andrew Thompson-Sutherland |
Proprietorship |
3200 Daniel Lane Apt. 207 Monroeville, PA 15146 |
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. |
2021-07-06 |
Andrew Thompson-Sutherland |
kschumacher@tricorinsurance.com |
Monroeville |
Allegheny |
PA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Thompson-Sutherland |
kschumacher@tricorinsurance.com |
Same |
Monroeville |
Allegheny |
PA |
Mitch Kemp |
Shuree Behr |
Signed |
558 |
2021-07-07 13:35 |
Anonymous (not verified) |
66.188.136.150 |
Austin Kalfus Sr. |
Proprietorship |
1203 Poppy Ave. Pensacola, FL 32507 |
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. |
2021-07-07 |
Austin Kalfus Sr. |
kschumacher@tricorinsurance.com |
Pensacola |
Escambia |
FL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Kalfus Sr. |
kschumacher@tricorinsurance.com |
Same |
Pensacola |
Escambia |
FL |
Mitch Kemp |
Shuree Behr |
Signed |
559 |
2021-07-08 08:27 |
Anonymous (not verified) |
66.188.136.150 |
Justin Keplinger |
Proprietorship |
8671 Hamby Rd. Morris, AL 35116 |
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. |
2021-07-07 |
Justin Keplinger |
kschumacher@tricorinsurance.com |
Morris |
Jefferson |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Keplinger |
kschumacher@tricorinsurance.com |
Same |
Morris |
Jefferson |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
560 |
2021-07-08 08:46 |
Anonymous (not verified) |
66.188.136.150 |
Darius Harvey |
Proprietorship |
2738 E 53rd. Apt. 7 Davenport, IA 52807 |
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. |
2021-07-07 |
Darius Harvey |
kschumacher@tricorinsurance.com |
Davenport |
Scott |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darius Harvey |
kschumacher@tricorinsurance.com |
Same |
Davenport |
Scott |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
561 |
2021-07-08 09:11 |
Anonymous (not verified) |
66.188.136.150 |
Aaron Maldonado dba ATM Trucking |
Proprietorship |
1011 Reynolds Drive, Charleston, IL 61920 |
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. |
2021-07-07 |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Same |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
562 |
2021-07-08 09:46 |
Anonymous (not verified) |
66.188.136.150 |
Rick Davis |
Proprietorship |
521 N 13th St. Salina, KS 67401 |
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. |
2021-07-07 |
Rick Davis |
kschumacher@tricorinsurance.com |
Salina |
Saline |
KS |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Davis |
kschumacher@tricorinsurance.com |
Same |
Salina |
Saline |
KS |
Mitch Kemp |
Shuree Behr |
Signed |
171 |
2020-06-01 16:17 |
Anonymous (not verified) |
99.203.98.130 |
Jose Jurado |
Limited Liability Company |
3825 NE 43rd ct Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-01 |
Jose Jurado |
trustedroofingllc@gmail.com |
Des Moines |
Polk |
IOWA |
Sterling Bean |
Sigifredo Corral |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Jurado |
trustedroofingllc@gmail.com |
Marcos Jurado |
Des Moines |
Polk |
IOWA |
Sterling Bean |
Sigifredo Corral |
Signed |
1358 |
2022-11-03 23:03 |
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 |
1910 |
2023-11-15 13:06 |
Anonymous (not verified) |
94.188.207.228 |
RODRIGUEZ ENTERPRISES III INC |
Limited Liability Company |
905 W US HIGHWAY 30 CARROLL IA 51401 |
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. |
2023-11-14 |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
CARROLL |
CARROLL |
IOWA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
OWNER |
CARROLL |
CARROLL |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
693 |
2021-10-26 15:03 |
Anonymous (not verified) |
65.144.174.26 |
Diamante Tile |
Proprietorship |
1403 Aspen Dr Adel, IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-26 |
Octavio Bermudez |
aerosobo@gmail.com |
Des Moines |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Octavio Bermudez |
aerosobo@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
1793 |
2023-08-09 15:23 |
Anonymous (not verified) |
94.188.205.174 |
Cesar estuardo marroquin gonzalez |
Proprietorship |
1212 David st waterloo iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-09 |
Cesar estuardo marroquin gonzalez |
marroquincesar1788@gmail.com |
1212 David st waterloo iowa |
Black haw |
Iowa |
Sonia Gomez |
Sonia Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar estuardo marroquin gonzalez |
marroquincesar1788@gmail.com |
Patrón |
1212 David st waterloo iowa |
Black hawn |
Iowa |
Sonia Gomez |
Sonia Gomez |
Signed |
2214 |
2024-05-08 13:49 |
Anonymous (not verified) |
94.188.205.168 |
Hagen Installation Solutions LLC |
Limited Liability Company |
725 Cole St Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-08 |
Clay Allen Hagen |
clay.hagenson@gmail.com |
Carlisle |
Warren |
Iowa |
Tyler Bumgardner |
Spencer Kissinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clay Allen Hagen |
clay.hagenson@gmail.com |
Same person |
Carlisle |
Warren |
Iowa |
Tyler Bumgardner |
Spencer Kissinger |
Signed |
1808 |
2023-08-17 17:17 |
Anonymous (not verified) |
94.188.205.168 |
Treimer Trucking LLC |
Limited Liability Company |
3277 102nd St. Durant, IA 52747-9524 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-17 |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Tipton |
Iowa |
United States |
Sydney Rae Lane |
Spencer Lea Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Self |
Tipton |
Iowa |
United States |
Syndey Rae Lane |
Spencer Lea Parsons |
Signed |
2200 |
2024-05-06 08:46 |
Anonymous (not verified) |
94.188.207.226 |
Dominguez Construction LLC |
Limited Liability Company |
1680 East Emma Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-05 |
Ramon Dominguez |
3memincolina@gmail.com |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ramon Dominquez |
3memincolina@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
1833 |
2023-09-08 13:39 |
Anonymous (not verified) |
94.188.207.225 |
Superior painting & epoxy coatings llc |
Limited Liability Company |
4918 ne crestmoor ln |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-05 |
Anthony Negrete jr |
superior.paint@hotmail.com |
Ankeny |
IA |
United States |
Stacey Marie stoecker |
Anthony Negrete jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Negrete jr |
superior.paint@hotmail.com |
Spouse |
Ankeny |
IA |
United States |
Anthony Negrete jr |
stacey marie Stoecker |
Signed |
1947 |
2023-12-07 16:01 |
Anonymous (not verified) |
94.188.205.176 |
Reinier Construction LLC |
Limited Liability Company |
1406 Linden Lane |
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. |
2023-12-07 |
David J Reinier |
reinierconst@aol.com |
Des Moines |
Polk |
IA |
PEGGY A ROHDE |
Douglas E Rohde |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PEGGY A ROHDE |
dnprohde@msn.com |
Bookkeeper |
Polk City |
Polk |
IA |
Douglas E Rohde |
Stacie L Miller |
Signed |
1340 |
2022-10-18 17:03 |
Anonymous (not verified) |
166.181.89.97 |
Stevens mobile welding services LLC |
Limited Liability Company |
5645 se 56th st. Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-18 |
Daniel Robert Stephens |
dannystephens303@gmail.com |
Carlisle |
Polk |
Iowa |
Nikita Marie Knapp |
Stacy Robin Stephens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Robert Stephens |
dannystephens303@gmail.com |
Owner |
Carlisle |
Polk |
Iowa |
Nikita Marie Knapp |
Stacy Robin Stephens |
Signed |
17 |
2019-12-31 09:24 |
Anonymous (not verified) |
72.35.186.80 |
Grgurich Dozing & Tiling, LLC |
Partnership |
PO Box 131, Williamson, IA 50272 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Seth Grgurich |
mcbroomt15@gmail.com |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Grgurich |
mcbroomt15@gmail.com |
Partner |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
1727 |
2023-07-07 18:26 |
Anonymous (not verified) |
94.188.205.169 |
D&E LLC DBA Kanesville Valley |
Limited Liability Company |
P.O. Box 337 Council Bluffs, IA, 51502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Edward Gregory |
eddegregory@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Gregory |
eddegregory@gmail.com |
Self |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
Signed |
2112 |
2024-03-22 08:22 |
Anonymous (not verified) |
94.188.205.174 |
WR TREE SERVICES |
Limited Liability Company |
1176 highway 9 Lansing iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-22 |
Wesley Adam Remund |
wesleyadamremund@gmail.com |
Lansing |
Allamakee |
Iowa |
JENNIFER K Harris |
Stefan M Remund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wesley Adam Remund |
wesleyadamremund@gmail.com |
OWNER |
Lansing |
Allamakee |
Iowa |
Jennifer K Harris |
Stefan M Remund |
Signed |
2100 |
2024-03-17 12:36 |
Anonymous (not verified) |
94.188.205.167 |
Donovan Electric LLC |
Limited Liability Company |
857 Tipperary rd Iowa City 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. |
2024-03-17 |
Bill Donovan |
bill@donovanelectricllc.com |
Iowa City |
Johnson |
IA |
Bo Nock |
Stephanie Ineichen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Donovan |
blaked@donovanelectricllc.com |
Partner |
Iowa City |
Johnson |
IA |
Bo Nock |
Stephanie Ineichen |
Signed |
909 |
2022-02-10 08:03 |
Anonymous (not verified) |
166.181.83.242 |
Kim Hildebrand |
Proprietorship |
130 Sabrina cir Waterloo, IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-07 |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Self |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
2001 |
2024-01-26 10:41 |
Anonymous (not verified) |
94.188.207.225 |
4 Sons Splicing & Activation |
Proprietorship |
13510 W Brazos Bend Dr, Needville, TX 77461-9525 |
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. |
2024-01-26 |
John Kevin Steil |
foursons1990@steil.org |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Helen Frances Steil |
foursons1990@steil.org |
Spouse |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
633 |
2021-09-08 10:35 |
Anonymous (not verified) |
208.95.1.97 |
BAJ Flooring, LLC |
Limited Liability Company |
31533 Castle Ct. Dyersville, IA. 52040-7600 |
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. |
2021-09-08 |
Brian Jacque |
JacqueBrian18@gmail.com |
Dyersville |
Dubuque |
Iowa |
Stephen J. Schluter |
Paula Fitzgerald |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Brian A. Jacque |
JacqueBrian18@gmail.com |
LLC MEMBER |
Dyersville |
DUBUQUE |
IOWA |
Stephen J. Schlueter |
Stephen J. Schlueter |
Signed |
306 |
2020-11-02 20:31 |
Anonymous (not verified) |
208.126.30.236 |
foust lawn care llc |
Limited Liability Company |
2999 st charles rd st charles ia 50240 |
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. |
2020-11-05 |
stephen howard foust |
shfoust53@gmail.com |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
stephen howard foust |
shfoust53@gmail.com |
self |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
1464 |
2023-02-17 15:05 |
Anonymous (not verified) |
94.188.205.166 |
Jordan Walkup |
Proprietorship |
5751 NE 22nd St Des Moines IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Jordan Walkup |
jordanw@bigroofing515.com |
Windsor Heights |
Polk |
IA |
Sarah Walkup |
Steve Bieghler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Walkup |
jordanw@bigroofing515.com |
Self |
Windsor Heights |
Polk |
IA |
Sarah Walkup |
Steve Bieghler |
Signed |
1614 |
2023-04-27 15:18 |
Anonymous (not verified) |
94.188.205.177 |
Crawford Construction Services LLC |
Limited Liability Company |
1018 Creston Ave, Des Moines, Ia 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
Casey D Crawford |
crawfordcasey8824@gmail.com |
Des Moines |
Polk |
Iowa |
Nicole Powell |
Steve Crawford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casey D Crawford |
crawfordcasey8824@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Nicole Powell |
Steve Crawford |
Signed |
1117 |
2022-05-18 10:33 |
Anonymous (not verified) |
74.84.106.106 |
Tina Owens |
Proprietorship |
4162 Hwy F62 West Monroe, Iowa 50170 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-18 |
Tina M Owens |
towens974447@yahoo.com |
Monroe |
Jasper |
Iowa |
Ashley Owens |
Steve Wimer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tina Owens |
towens974447@yahoo.com |
self |
Monroe |
Jasper |
Iowa |
Ashley Ann Owens |
Steve Edwin Wimer |
Signed |
1843 |
2023-09-14 14:12 |
Anonymous (not verified) |
94.188.205.167 |
Rosenbum Construction, LLC |
Limited Liability Company |
720 South Street, Arlington, Iowa 50606 |
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 |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Self |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
1844 |
2023-09-14 14:15 |
Anonymous (not verified) |
94.188.205.177 |
Royal Gutters & Construction, LLC |
Limited Liability Company |
1420 120th Street, Hazleton, IA 50641 |
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. |
2023-04-01 |
Andy Hershberger |
hershbergera@gmail.com |
Hazleton |
Buchanan |
Iowa |
Eli Raber |
Steve Frost |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andy Herschberger |
hershbergera@gmail.com |
self |
Hazleton |
Buchanan |
Iowa |
Eli Miller |
Steve Frost |
Signed |