1513 |
2023-03-13 06:54 |
Anonymous (not verified) |
94.188.205.169 |
Tyler Ankney |
Proprietorship |
1250 A Avenue, Marion, IA 52302, United States |
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 |
Tyler Ankney |
T_james55@ahoo.com |
Marion |
Linn County |
Iowa |
Jordan Nisiewicz |
Steve Gisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Steve Gisler |
Signed |
809 |
2021-12-21 14:42 |
Anonymous (not verified) |
75.162.173.166 |
Mike Money |
Proprietorship |
3506 Glover Ave. Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-21 |
Michael David Money |
poojennings78@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael David Money |
poojennings78@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
1302 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
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. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
1303 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
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. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
1304 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
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. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
377 |
2021-01-26 13:31 |
Anonymous (not verified) |
184.63.6.1 |
Matt Reynolds |
Proprietorship |
684 Cedar Valley Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-26 |
Matt Reynolds |
matt.reynolds0891@gmail.com |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Reynolds |
matt.reynolds0891@gmail.com |
Proprietorship |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
370 |
2021-01-22 14:23 |
Anonymous (not verified) |
71.39.227.238 |
Jonathon McClure |
Proprietorship |
25059 R Ave, 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. |
2021-01-22 |
Jonathon McClure |
mcclure.jonathon@gmail.com |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathon McClure |
mcclure.jonathon@gmail.com |
Self |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
371 |
2021-01-22 14:25 |
Anonymous (not verified) |
71.39.227.238 |
Michael McClure |
Proprietorship |
2553 240th St, Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-22 |
Michael McClure |
mdjj4@centurylink.net |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael McClure |
mdjj4@centurylink.net |
Self |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
957 |
2022-03-08 14:54 |
Anonymous (not verified) |
71.39.227.238 |
Sharol Williams |
Proprietorship |
1605 Ash St, Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-08 |
Sharol Williams |
sharolann48@gmail.com |
Dallas Center |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sharol Williams |
SharolAnn48@gmail.com |
Self |
Dallas Center |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
654 |
2021-09-24 15:08 |
Anonymous (not verified) |
199.247.64.87 |
Steve Porter DBA Precision Striping |
Proprietorship |
408 Embassy Ct. Sergeant Bluff, IA 51054 |
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. |
2021-09-23 |
Steve Porter |
steve.porter2710@gmail.com |
Sergeant Bluff |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jana Reich |
JNeuzil@reichpainting.com |
Office Manager |
Sioux City |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
1036 |
2022-04-06 10:22 |
Anonymous (not verified) |
67.212.111.166 |
Precision Painting |
Proprietorship |
507 Broad Street, Reinbeck Iowa 50669 |
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. |
2022-04-06 |
Dan Bowser |
dbowser.precision.painting@gmail.com |
Reinbeck |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
1072 |
2022-04-26 16:17 |
Anonymous (not verified) |
166.182.80.187 |
N & S Trucking Inc |
Limited Liability Company |
3061 170Th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-26 |
Steven Kirk Van Ommen |
Stevevo74@yahoo.com |
Riverside |
Iowa |
United States |
Steve Van Ommen |
Steve Van Ommen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Kirk Van Ommen |
Stevevo74@yahoo.com |
President |
Riverside |
IA |
United States |
Steve Van Ommen |
Steve Van Ommen |
Signed |
112 |
2020-04-07 12:16 |
Anonymous (not verified) |
173.27.33.108 |
Josh Alley Siding |
Proprietorship |
205 N Oak St. Davis City, IA 50065 |
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. |
2018-04-10 |
Joshua H. Alley |
alley.josh@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Alley Siding |
alley.josh@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
113 |
2020-04-07 12:30 |
Anonymous (not verified) |
173.27.33.108 |
Aarron Alley |
Proprietorship |
101 S Teale 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. |
2018-05-15 |
Aarron Alley |
aarronalley10@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aarron Alley |
aarronalley10@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
308 |
2020-11-08 09:17 |
Anonymous (not verified) |
173.27.33.108 |
Aarron Alley |
Proprietorship |
101 S Teale St. Davis City, 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. |
2019-11-01 |
Aarron Alley |
aarronalley10@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aarron Alley |
aarronalley10@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
1453 |
2023-02-14 07:19 |
Anonymous (not verified) |
94.188.207.230 |
Milton Gray |
Proprietorship |
255 10th Ave., Marion, IA 52302, US |
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. |
2023-02-13 |
Milton Gray |
miltongray23@gmail.com |
Marion, IA |
Linn |
Iowa |
Jordan Nisiewicz |
Charles Wood |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
MO |
Charles Wood |
Steven Geisler |
Signed |
1794 |
2023-08-10 14:56 |
Anonymous (not verified) |
94.188.205.169 |
Alex Kiler |
Proprietorship |
10511 Main Road, La Porte City, IA 50651, United States |
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. |
2023-08-10 |
Alex Kiler |
alexkiler12622@gmail.com |
La Porte City, IA |
Black Hawk County |
Iowa |
Charles Woods |
Steve Geisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Charles Wood |
Steven Geisler |
Signed |
834 |
2022-01-12 17:34 |
Anonymous (not verified) |
67.212.111.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 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. |
2021-01-13 |
Erik Bjorn Nelson |
ebjornnelson@gmail.com |
Waterloo |
Black Hawk County |
Iowa |
Kari Houle |
Steven John Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Steven John Swanson |
Signed |
2023 |
2024-02-05 21:11 |
Anonymous (not verified) |
94.188.205.176 |
Joey Pohlen |
Proprietorship |
4552 400th St. Hospers, Iowa 51238 |
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. |
2024-02-05 |
Joseph Dale Pohlen |
joey.pohlen18@gmail.com |
Hospers |
Sioux |
Iowa |
Joseph Clarence Pohlen |
Steven Laurence Auchstetter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Dale Pohlen |
joey.pohlen18@gmail.com |
owner |
Hospers |
Sioux |
Iowa |
Joseph Clarence Pohlen |
Steven Laurence Auchstetter |
Signed |
2143 |
2024-04-09 13:05 |
Anonymous (not verified) |
94.188.207.230 |
CO2 Refrigeration Systems (Iowa) LLC |
Limited Liability Company |
315 E 5th St Ste 202, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-04-09 |
Zachary Heintz Laws |
zach.laws@co2refsystems.com |
Marshalltown |
Marshall |
Iowa |
Robert E Shomo |
Steven M Madsen |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Zachary Heintz Laws |
zach.laws@co2refsystems.com |
Self |
Marshalltown |
Marshall |
Iowa |
Robert E Shomo |
Steven M Madsen |
Signed |
1214 |
2022-07-20 09:51 |
Anonymous (not verified) |
173.23.180.117 |
Eric Morse |
Proprietorship |
1610 Hawthorne Ave, Waterloo, IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-09 |
Eric Richard Morse |
ericmorse82@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Christine Diane Willis (notary) |
Steve Sprague |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Morse |
ericmorse82@gmail.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Christine Diane Willis (notary) |
Steven Sprague |
Signed |
1108 |
2022-05-16 16:14 |
Anonymous (not verified) |
4.4.30.34 |
David Sickels |
Proprietorship |
2221 Radcliffe Drive SW, Cedar Rapids, IA 52404 |
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. |
2022-05-16 |
David Sickels |
glsickels@gmail.com |
Cedar Rapids |
IA |
United States |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Allen Sickels |
glsickels@gmail.com |
self |
Cedar Rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
1940 |
2023-12-05 15:11 |
Anonymous (not verified) |
94.188.207.227 |
David Sickels |
Proprietorship |
2221 Radcliffe drive s.w cedar rapids 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. |
2023-11-05 |
David Sickels |
davidasickels@gmail.com |
Cedar rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Allen Sickels |
davidasickels@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
904 |
2022-02-08 08:11 |
Anonymous (not verified) |
173.23.180.117 |
Dawg House Renovation |
Limited Liability Company |
113 Allen St Waterloo Iowa 50701 |
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. |
2022-02-08 |
Steve Sprague |
dawghouse729@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Paula Sprague |
Stewart Sprague |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Sprague |
dawghouse729@Gmail.Com |
Self |
Waterloo |
Black Hawk |
Iowa |
Paula Sprague |
Stewart Sprague |
Signed |
906 |
2022-02-09 08:57 |
Anonymous (not verified) |
173.28.0.37 |
CAB Holdings LLC |
Limited Liability Company |
804 SE Cherry ST Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Kristy Briles |
kristyabriles@gmail.com |
Des Moines |
Polk |
IA |
Stephanie Seymour |
Sue Briles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristy Briles |
kristyabriles@gmail.com |
owner |
Des Moines |
Polk |
IOwa |
Stephanie Seymour |
Sue Briles |
Signed |
907 |
2022-02-09 08:59 |
Anonymous (not verified) |
173.28.0.37 |
Rusty K5 LLC |
Limited Liability Company |
804 SW Cherry St Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Kristy Briles |
kristyabriles@gmail.com |
Des Moines |
Polk |
IA |
Stephanie Seymour |
Sue Briles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristy Briles |
kristyabriles@gmail.com |
Owner |
Des moines |
Polk |
IA |
50313 |
Sue Briles |
Signed |
1718 |
2023-06-29 12:36 |
Anonymous (not verified) |
94.188.205.166 |
Aidan Obermueller |
Proprietorship |
2520 N Grandview Avenue, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-27 |
Aidan Obermueller |
aidanobermueller@icloud.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aidan Obermueller |
aidanobermueller@icloud.com |
self |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miler |
Signed |
1417 |
2023-01-11 08:55 |
Anonymous (not verified) |
174.235.209.245 |
Standard Insulation Company, LLC |
Limited Liability Company |
1066 Prairieview Ave., Van Meter, IA 50261 |
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. |
2023-01-11 |
Mitchell Simonson |
standard.insulation@outlook.com |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Simonson |
standard.insulation@outlook.com |
Owner |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
782 |
2021-12-08 10:11 |
Anonymous (not verified) |
173.21.158.248 |
Barry Duncan |
Proprietorship |
2020 S.E. Four Seasons Dr., 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. |
2021-12-08 |
BARRY DUNCAN |
bduncan1452@gmail.com |
Ankeny |
IA |
Iowa |
Kathy Belieu |
Summer Belieu-Slemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BARRY DUNCAN |
bduncan1452@gmail.com |
Self |
Ankeny |
Polk |
Iowa |
Kathy Belieu |
Summer Belieu-Slemp |
Signed |
2123 |
2024-03-28 10:42 |
Anonymous (not verified) |
94.188.207.229 |
J&J Masonry |
Proprietorship |
2519 Poppleton 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. |
2024-03-28 |
Jose Marroquin |
drakkarhr7@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Marroquin |
drakkarhr7@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2126 |
2024-03-29 09:35 |
Anonymous (not verified) |
94.188.207.227 |
MPO Masonry |
Proprietorship |
5027 s 20th at apt 12 Omaha ne 68107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-29 |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2128 |
2024-03-29 09:52 |
Anonymous (not verified) |
94.188.207.228 |
Mason Quality and Sons LLC |
Proprietorship |
18921 Willow St Omaha Ne 68136 |
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 |
Joel Castillo |
drake.centurion@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Castillo |
drake.centurion@gmail.com |
self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
1367 |
2022-11-11 11:06 |
Anonymous (not verified) |
173.29.231.17 |
Sosa Flooring |
Proprietorship |
2310 NE 16TH Ankeny, Iowa 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. |
2022-11-11 |
Zeferino Alcantara Sosa |
sunnysosa@aol.com |
Ankeny |
Polk |
Iowa |
Ashley Temple |
Sunny Sosa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zeferino Alcantara Sosa |
sunnysosa@aol.com |
OWNER |
Ankeny |
Polk |
Iowa |
Ashley Temple |
Sunny Sosa |
Signed |
603 |
2021-08-14 09:39 |
Anonymous (not verified) |
173.20.168.51 |
Leaf Filter |
Proprietorship |
3060 Southeast Grimes Boulevard |
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. |
2021-08-14 |
Francisco Salgado |
fsalgado1989@gmail.com |
Perry |
IA |
United States |
Wendy Asturias |
Susana Romero |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Leaf Filter |
macosta@leafhome.com |
none |
Grimes |
Polk |
Iowa |
Wendy Asturias |
Susana Romero |
Signed |
1651 |
2023-05-16 22:18 |
Anonymous (not verified) |
94.188.205.175 |
Corridor Cleaning Services, LLC |
Limited Liability Company |
4621 Orchard Dr NW, Cedar Rapids, Iowa, 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-11 |
Andrew Kleineck |
andrew@corridorcleaning.net |
Cedar Rapids |
Linn |
Iowa |
Cole Smith |
Suzanne Brue |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Kleineck |
andrew@corridorcleaning.net |
LLC Member |
Cedar Rapids |
Linn |
Iowa |
Cole Smith |
Suzanne Brue |
Signed |
1660 |
2023-05-24 10:11 |
Anonymous (not verified) |
94.188.205.177 |
Might Lawn Care |
Limited Liability Company |
1920 W 70th St. Davenport, IA 52806 |
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. |
2023-05-24 |
Meredith Whitney Might |
mightlawncare@gmail.com |
Davenport |
Scott |
IA |
Samuel Lawrence Might |
Suzette Henriksen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meredith Might |
mightlawncare@gmail.com |
Owner |
Davenport |
Scott |
IA |
Samuel Lawrence Might |
Suzette Henriksen |
Signed |
1661 |
2023-05-24 10:12 |
Anonymous (not verified) |
94.188.205.167 |
Might Lawn Care |
Limited Liability Company |
1920 W 70th St. Davenport, IA 52806 |
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. |
2023-05-24 |
Samuel Lawrence Might |
mightlawncare@gmail.com |
Davenport |
Scott |
IA |
Meredith Might |
Suzette Henriksen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samuel Might |
mightlawncare@gmail.com |
Owner |
Davenport |
Scott |
IA |
Meredith Might |
Suzette Henriksen |
Signed |
1992 |
2024-01-18 21:51 |
Anonymous (not verified) |
94.188.205.175 |
NB Tile |
Proprietorship |
13310 NE 112th 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. |
2024-01-18 |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Maxwell |
IA |
United States |
Kevin Orr |
Sydney Paustian |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Owner |
Mawell |
Polk |
Iowa |
Kevin Orr |
Sydney Paustian |
Signed |
1803 |
2023-08-15 19:03 |
Anonymous (not verified) |
94.188.207.224 |
Teimer 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. |
2023-08-15 |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Tipton |
Iowa |
United States |
Spencer Lea Parsons |
Sydney Rae Lane |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Self |
Tipton |
Iowa |
United States |
Spencer Lea Parsons |
Sydney Rae Lane |
Signed |
1039 |
2022-04-11 14:33 |
Anonymous (not verified) |
199.120.121.97 |
Panama Electric |
Proprietorship |
106 S Railway Panama IA 51562 |
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. |
2022-04-11 |
Dan Wingert |
danwingert@fmctc.com |
Panama |
Shelby |
IA |
Laura Wingert |
Sylvan Kenkel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Wingert |
danwingert@fmctc.com |
Self |
Panama |
Shelby |
IA |
Laura Wingert |
Sylvan Kenkel |
Signed |
472 |
2021-04-13 10:58 |
Anonymous (not verified) |
65.103.82.36 |
Scrap And More |
Proprietorship |
1303 W Linn St. Marshalltown, IA. 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-05-01 |
Travis Bachman |
na@yahoo.com |
marshalltown |
marshall |
IA |
sarah |
Tami |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Bachman |
na@yahoo.com |
owner |
marshalltown |
marsahll |
IA |
sara |
tami |
Signed |
501 |
2021-04-29 15:47 |
Anonymous (not verified) |
184.179.6.93 |
Rodney Bohannon |
Proprietorship |
5221 Crogans Way Rd, Council Bluffs IA 51501 |
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. |
2021-04-29 |
Rodney Bohannon |
bohannonrod@gmail.com |
Council Bluffs |
POTTAWATTAMIE |
iowa |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodney Bohannon |
bohannonrod@gmail.com |
Owner |
Council Bluffs |
POTTAWATTAMIE |
IA |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
179 |
2020-06-09 11:22 |
Anonymous (not verified) |
173.31.147.225 |
SAUL GUERARA MEZA |
Proprietorship |
26 WESTVIEW DRIVE APT 5 MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-21 |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
1756 |
2023-07-20 11:19 |
Anonymous (not verified) |
94.188.205.169 |
LEVI GONZALEZ |
Proprietorship |
2212 OKOBOJI AVE MILFORD, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-13 |
LEVI GONZALEZ |
joel@walkerinsuranceia.com |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LEVI GONZALEZ |
JOEL@WALKERINSURANCEIA.COM |
SELF |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI KLEIN |
Signed |
1836 |
2023-09-11 09:26 |
Anonymous (not verified) |
94.188.205.174 |
Felisha Schmitz |
Proprietorship |
505 Q AVENUE MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-08 |
FELISHA SCHMITZ |
PETERNFISH@GMAIL.COM |
MILFORD |
DICKINSON |
IA |
JENNIFER YOUNGWIRTH |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
FELISHA SCMITZ |
PETERNFISH@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IA |
JENNIFER YOUNGWIRTH |
TAMI KLEIN |
Signed |
41 |
2020-01-20 14:26 |
Anonymous (not verified) |
173.24.181.211 |
BARBARA HOOGEVEEN |
Proprietorship |
304 MILL POND RD, ROCK RAPIDS, IA 51246 |
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. |
2020-01-20 |
BARBARA HOOGEVEEN |
MCGILLH@MTCNET.NET |
ROCK RAPIDS |
LYON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BARABARA HOOGEVEEN |
MCGILLH@MTCNET.NET |
OWNER |
ROCK RAPIDS |
LYON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
42 |
2020-01-24 12:26 |
Anonymous (not verified) |
173.24.181.211 |
MIKE EDDY |
Proprietorship |
PO BOX 437 OKOBOJI, IA 51355 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-22 |
MIKE EDDY |
joel@walkerinsuranceia.com |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MIKE EDDY |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
44 |
2020-01-28 12:55 |
Anonymous (not verified) |
173.24.181.211 |
AMANDA FIEDLER |
Proprietorship |
10 5TH AVE NW FOSTORIA, IA 51340 |
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. |
2020-01-28 |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
FOSTORIA |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
FOSTORIA |
CLAY |
IA |
JOSPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
96 |
2020-03-19 12:11 |
Anonymous (not verified) |
173.24.181.211 |
JENSEN GROUP LP |
Limited Liability Partnership |
PO BOX 721 ARNOLDS PARK, IA 51331 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
MICHAEL JENSEN |
Michael@BuyGreatLakes.com |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MICHAEL JENSEN |
JOEL@WALKERINSURANCE.COM |
PARTNER |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
327 |
2020-11-25 10:38 |
Anonymous (not verified) |
173.31.147.225 |
CASEY KYLE |
Proprietorship |
1505 9TH ST MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
CASEY KYLE |
JOEL@WALKERINSURANCEIA.COM |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CASEY KYLE |
JOEL@WALKERINSURANCEIA.COM |
SELF |
MILFORD |
DISCKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |