25 |
2020-01-03 13:09 |
Anonymous (not verified) |
74.84.121.206 |
Raymond Jones |
Proprietorship |
P O Box 682 Monona IA 52159 |
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. |
2019-11-29 |
Raymond Jones |
darrele@ciains.biz |
Monona |
Clayton |
Iowa |
Darrel J Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel J Elsbernd |
darrele@ciains.biz |
insurance agent |
Lime Springs |
Howard |
Iowa |
Darrel J Elsbernd |
Chris Fye |
Signed |
34 |
2020-01-10 15:56 |
Anonymous (not verified) |
74.84.121.206 |
Milferd Loewen |
Proprietorship |
6568 Hwy 63, Lime Springs, IA 52155 |
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. |
2020-01-10 |
Milferd Loewen |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Milferd Loewen |
darrele@ciains.biz |
self |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
1472 |
2023-02-20 15:52 |
Anonymous (not verified) |
94.188.207.230 |
C & A Fox Farms LLC |
Limited Liability Company |
3275 Valley Ave Orchard IA 50460 |
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. |
2023-02-20 |
Curtis Fox |
sales@foxfarmsllc.com |
Orchard |
IOWA |
United States |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Curtis Fox |
sales@foxfarmsllc.com |
Self |
Orchard |
IOWA |
United States |
Darrel Elsbernd |
Chris Fye |
Signed |
1473 |
2023-02-20 15:57 |
Anonymous (not verified) |
94.188.207.224 |
C & A Fox Farms LLC |
Limited Liability Company |
3275 valley Ave Orchard IA 50460 |
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. |
2023-02-20 |
Allen Fox |
sales@foxfarmsllc.com |
Orchard |
Mitchell |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Allen Fox |
sales@foxfarmsllc.com |
self |
Orchard |
Mitchell |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
1499 |
2023-03-07 11:21 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Zimmerman |
Proprietorship |
17606 35th St Lime Springs, 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. |
2022-04-27 |
Ryan Zimmerman |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
1501 |
2023-03-07 11:27 |
Anonymous (not verified) |
94.188.205.167 |
Adriene Dangler |
Proprietorship |
2400 South Shore Dr Clear Lake, IA 50428 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Adrienne Dangler |
darrele@ciains.biz |
Clear Lake |
Cerro Gordo |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Clear Lake |
Cerro Gordo |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
1503 |
2023-03-07 12:45 |
Anonymous (not verified) |
94.188.205.177 |
Al's Roofing LLC |
Limited Liability Company |
P O Box 277 Lime Springs, 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. |
2022-04-18 |
John Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
275 |
2020-10-08 11:56 |
Anonymous (not verified) |
166.224.213.71 |
Michael corcoran |
Proprietorship |
311 e elm 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. |
2020-10-07 |
Michael corcoran |
mikecorcoran1990@gmail.com |
West Union |
Fayette |
IA |
Heather corcoran |
Chris Fels |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael corcoran |
mikecorcoran1990@gmail.com |
Self |
West Union |
Fayette |
IA |
Heather corcoran |
Chris fels |
Signed |
595 |
2021-08-03 13:53 |
Anonymous (not verified) |
174.248.224.252 |
Joseph r cunningham dba freedom field services |
Proprietorship |
6285 n 67th ave w Baxter iowa 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-03 |
Joseph r Cunningham jr. |
joecunningham1966@protonmail.com |
Baxter |
Jasper |
Iowa |
Chelsey Cunningham |
Chris Cort |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph r cunningham jr |
joecunningham1966@protonmail.com |
Me |
Baxter |
Jasper |
Iowa |
Chelsey cunningham |
Chris cort |
Signed |
963 |
2022-03-10 10:51 |
Anonymous (not verified) |
173.29.157.192 |
Thompson Servcies LLC |
Limited Liability Company |
21105 N Brady 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. |
2022-03-10 |
Daniel M Konrardy |
dkonrardy64@yahoo.com |
Davenport |
Scott |
Iowa |
David Konrardy |
Cheryl Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel M Konrardy |
dkonrardy64@yahoo.com |
LLC member/partner |
Davenport |
Scott |
Iowa |
David Konrardy |
Cheryl Thompson |
Signed |
905 |
2022-02-08 10:23 |
Anonymous (not verified) |
74.115.101.41 |
Triple TTT Transport, LLC |
Limited Liability Company |
307 7th Avenue SE, Belmond, IA 50541 |
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 |
Clint C Christians |
christiansclint0@gmail.com |
Pocahontas |
pocahontas |
Iowa |
Dale R Eng |
Cheri Zimmerman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clint Christians |
christiansclint0@gmail.com |
Partner |
Pocahontas |
Pocahontas |
Iowa |
Dale Eng |
Cheri Zimmerman |
Signed |
135 |
2020-04-28 10:04 |
Anonymous (not verified) |
74.84.101.138 |
W.A.D.E., Inc. DBA Decorah Cleaners |
Proprietorship |
504 Heivly Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Darrin Walter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrin Walter |
chelsea.whalen@upperiowains.com |
Owner |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
136 |
2020-04-28 10:06 |
Anonymous (not verified) |
74.84.101.138 |
W. A. D. E., Inc. DBA Decorah Cleaners |
Proprietorship |
504 Heivly Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Owner |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
158 |
2020-05-18 13:58 |
Anonymous (not verified) |
108.59.100.21 |
LNM Truck & Trailer Repair LLC |
Limited Liability Company |
902 Rossville Rd, Waukon, IA 52172 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-05-18 |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Owner |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
176 |
2020-06-07 08:23 |
Anonymous (not verified) |
174.16.51.128 |
TrueFood LLC |
Limited Liability Company |
2055 Nature Ave Stanton IA 51573 |
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. |
2020-04-24 |
Brian Barkman |
brian.barkman@truefood.farm |
Georgetown |
Williamson |
Texas |
Wanda Barkman |
Chelsea Church |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Barkman |
brian.barkman@truefood.farm |
TrueFood LLC is owned by agent |
Stanton |
Montgomery |
IA |
Wanda Barkman |
Chelsea Church |
Signed |
209 |
2020-07-19 17:02 |
Anonymous (not verified) |
173.189.166.183 |
Merle Fox |
Proprietorship |
314 N Jackson 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. |
2020-07-19 |
Merle T Fox |
merletravisfox.79@gmail.com |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle Fox |
merletravisfox.79@gmail.com |
self |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
1562 |
2023-04-10 07:43 |
Anonymous (not verified) |
94.188.205.174 |
JB Concrete and Construction |
Limited Liability Company |
306 1st Ave N.W Dayton Ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-10 |
JaredBerglund |
jaredberglund71@gmail.com |
Dayton |
Webster |
Iowa |
Travis Sonksen |
Chase Haman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JaredBerglund |
jaredberglund71@gmail.com |
Owner |
Dayton |
Webster |
Iowa |
Travis Sonksen |
Chase Haman |
Signed |
481 |
2021-04-14 17:15 |
Anonymous (not verified) |
199.66.15.81 |
K3 Recycling |
Limited Liability Company |
601 W. 1st 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. |
2021-04-14 |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charlie Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Same person |
Indianola |
IA |
IA |
Kristy Kappelman |
Charlie Kappelman |
Signed |
1195 |
2022-07-08 13:24 |
Anonymous (not verified) |
174.198.67.66 |
Chapas Construction |
Limited Liability Company |
6424 Roseland Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Polibio Raul Chapa Farez |
chapasconstructionllc@gmail.com |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Polibio Raul Chapa |
chapasconstructionllc@gmail.com |
President |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
1857 |
2023-10-02 16:33 |
Anonymous (not verified) |
94.188.205.169 |
Noah Blount |
Proprietorship |
2611 capitol ave, Des Moines, IA 50317, 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. |
2023-10-02 |
Noah Blount |
nbeav5@gmail.com |
Des Moines |
Des Moines |
Iowa |
Jordan Loyd |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Jackson |
Missouri |
Jordan Loyd |
Charles Woods |
Signed |
1629 |
2023-05-09 08:50 |
Anonymous (not verified) |
94.188.207.223 |
Alex Jones |
Proprietorship |
2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State |
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. |
2023-05-09 |
Alex Jones |
ajones0425@yahoo.com |
Cedar Rapids |
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 |
Missouri |
Jordan Loyd |
Charles Wood |
Signed |
1828 |
2023-09-06 14:43 |
Anonymous (not verified) |
94.188.205.177 |
Des Moines Smart Solutions LLC. |
Proprietorship |
1329 56th st, Des Moines, IA 50311, 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. |
2023-09-06 |
Denzel Colocho |
alejandro_colcho@yahoo.com |
Des Moines, IA |
Polk |
Iowa |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
MO |
Jordan Loyd |
Charles Wood |
Signed |
1169 |
2022-06-23 16:23 |
Anonymous (not verified) |
159.45.71.17 |
Whitlow Remodeling and Home Services, LLC |
Limited Liability Company |
6421 NW 54th Ct Johnston Iowa 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
Scot Alan Whitlow |
resaw375@msn.com |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scot Alan Whitlow |
resaw375@msn.com |
Owner |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
994 |
2022-03-22 12:19 |
Anonymous (not verified) |
75.162.125.176 |
performance painting llc |
Limited Liability Company |
4905 nw 4th street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-22 |
thomas lilly |
TLilly816@aol.com |
ankeny |
IOWA |
United States |
Sharon kay Gaulke |
Charles Thomas Cater |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Performance Painting LLC |
TLilly816@aol.com |
owner |
ankeny |
IOWA |
United States |
Sharon Kay Gaulke |
Charles Thomas Cater |
Signed |
937 |
2022-02-25 11:55 |
Anonymous (not verified) |
174.242.226.43 |
K3 Recycling |
Limited Liability Company |
510 West 2nd Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-25 |
Justin Kappelman |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Kappelman |
justin@kappelmanappliance.com |
Same |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
2108 |
2024-03-20 12:51 |
Anonymous (not verified) |
94.188.207.230 |
Mc Storm Restortion Services |
Limited Liability Company |
1913 NE LITTLE BEAVER DR |
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. |
2024-03-20 |
Michael Cross |
crossmichael1@hotmail.com |
Grimes |
IA |
United States |
Courtney Lesher |
Chandler Steffy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Cross |
crossmichael1@hotmail.com |
owner |
Grimes |
IA |
United States |
Courtney Lesher |
Chandler Steffy |
Signed |
1612 |
2023-04-27 10:37 |
Anonymous (not verified) |
94.188.207.223 |
Grind Works LLC |
Proprietorship |
26416 289th place Unit H Adel IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
Adam Samuelson |
Hello@grindworksia.com |
Adel |
Dallas |
Iowa |
Chandler Clark |
Adam Samuelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Samuelson |
Hello@Grindowrksia.com |
N/A |
Adel |
Dallas |
Iowa |
Adam Samuelson |
Chandler Clark |
Signed |
433 |
2021-03-12 20:47 |
Anonymous (not verified) |
173.28.1.65 |
HomeTeam painting llc |
Limited Liability Company |
3810 Amherst Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-12 |
Johnny ollin |
johnnyollin@gmail.com |
DesMoines |
Polk |
IOWA |
David Carney |
Chad Winslow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Johnny ollin |
johnnyollin@gmail.com |
Myself |
DesMoines |
Polk |
IOWA |
David Carney |
Chad Winslow |
Signed |
1120 |
2022-05-19 09:49 |
Anonymous (not verified) |
65.125.92.130 |
JG Landscaping, LLC |
Limited Liability Company |
317 E 23rd St. 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. |
2022-05-19 |
Javier Alexander Guzman |
alexguz76@outlook.com |
Des Moines |
Polk |
IA |
Brenda Reedy |
Chad Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier Alexander Guzman |
alexguz76@outlook.com |
Self |
Des Moines |
Polk |
IA |
Brenda Reedy |
Chad Smith |
Signed |
1454 |
2023-02-14 09:34 |
Anonymous (not verified) |
94.188.207.227 |
Spencer Imaging Center, LLC |
Limited Liability Company |
710 S. Grand Ave., Spencer, IA 51301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-14 |
Alexander Pruitt |
apruitt@ncn.net |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad Roemeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Muller |
mullerwilliam@hotmail.com |
Co owner |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad Roemeling |
Signed |
1652 |
2023-05-17 20:44 |
Anonymous (not verified) |
94.188.205.167 |
Fox Trucking |
Proprietorship |
2774 March Ave Greene Ia. 50636 |
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. |
2023-05-17 |
Chet D. Fox |
cjakfox@yahoo.com |
Greene |
Floyd |
Iowa |
Jack Dwyer |
Chad Olson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chet Fox |
cjakfox@yahoo.com |
myself |
Greene |
Floyd |
Iowa |
Jack Dwyer |
Chad Olson |
Signed |
2056 |
2024-02-24 08:17 |
Anonymous (not verified) |
94.188.207.230 |
C&C Property LLC |
Limited Liability Partnership |
PO Box 418 |
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. |
2024-02-24 |
Joshua Darwin Wessel |
wesselclublambs@gmail.com |
Kiron |
Crawford |
IA |
Chad D Foust |
Chad A Tweeten |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Tweeten |
tweeten@hotmail.com |
Barn Manager 1099 employee |
Eagle grove |
Wright |
Iowa |
Chad Tweeten |
Chad Foust |
Signed |
1555 |
2023-04-05 08:03 |
Anonymous (not verified) |
94.188.207.227 |
DK Motor Freight |
Proprietorship |
3621 Tyler Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-05 |
David Kirchner |
dkirchner89@gmail.com |
Hartley |
Obrien |
Iowa |
Janna VanDonge |
Chad Driesen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Kirchner |
dkirchner89@gmail.com |
Self |
Hartley |
Iowa |
United States |
Janna VanDonge |
Chad Driesen |
Signed |
1787 |
2023-08-07 13:15 |
Anonymous (not verified) |
94.188.205.177 |
Dryseal Roofing and Construction |
Proprietorship |
390 olive st. Martensdale, Iowa 50160 |
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. |
2023-08-07 |
Travis w. Tibbits |
travistibbits@yahoo.com |
Martensdake |
Warren |
Iowa |
Dawn Marie tibbits |
Chad David walker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Wayne Tibbits |
travistibbits@yahoo.com |
Self |
Martensdale |
Warren |
Iowa |
Dawn Marie Tibbits |
Chad David walker |
Signed |
525 |
2021-05-18 09:42 |
Anonymous (not verified) |
50.82.130.211 |
Adrian Bernard |
Proprietorship |
803 Russell Circle, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-07 |
Adrian Bernard |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Bernard |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Chad Campbell |
Signed |
286 |
2020-10-21 18:32 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
1445 |
2023-02-08 14:56 |
Anonymous (not verified) |
94.188.207.225 |
Spencer Imaging Center, LLC |
Limited Liability Company |
710 S. Grand 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. |
2023-02-08 |
William Jay Muller |
mullerwilliam@hotmail.com |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad A Roemeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alexander Pruitt |
apruitt@ncn.net |
Partner |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad A Roemeling |
Signed |
1974 |
2024-01-04 13:12 |
Anonymous (not verified) |
94.188.205.167 |
Cro Outdoor Services, LLC |
Limited Liability Company |
1616 NW 78TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-20 |
Bojan Djukic |
Croodsia@gmail.com |
Clive |
Iowa |
United States |
Cezar Villalobos |
Maria Villalobos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evetee Villalobos |
e.villalobos91@gmail.com |
s/o |
Clive |
IA |
United States |
Maria Villalobos |
Cezar Villalobos |
Signed |
551 |
2021-06-29 09:18 |
Anonymous (not verified) |
72.168.160.90 |
BERNARD WATERBECK |
Limited Liability Company |
1353 280TH STREET, GARWIN, IOWA 50632 |
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. |
2021-06-29 |
BERNARD WATERBECK |
garwinacres2012@hotmail.com |
GARWIN |
TAMA |
IOWA |
DEAN KELLER |
CESAR MARROQUIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BERNARD WATERBECK |
garwinacres2012@hotmail.com |
SAME PERSON |
GARWIN |
TAMA |
IOWA |
DEAN KELLER |
CESAR MARROQUIN |
Signed |
1602 |
2023-04-25 20:10 |
Anonymous (not verified) |
94.188.207.228 |
Miguel D. |
Limited Liability Company |
1221 22nd st des moines ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-21 |
Miguel Duron |
Duron6478@gmail.com |
Des moines |
Polk |
Ia |
Uziel martinez |
Cesar jaz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Duron |
Diron6478@gmail.com |
Self |
Des moines |
Polk |
Iowa |
Uziel Martinez |
Cesar jaz |
Signed |
1252 |
2022-08-12 13:11 |
Anonymous (not verified) |
166.181.85.235 |
Cesar cardenas |
Proprietorship |
48644 roma valley dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-06 |
Cesar Octavio Cardenas navarrete |
cesarcardenas981@gmail.com |
Des moines |
Polk |
Iowa |
Cesar cardenas navarrete |
Cesar cardenas Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar cardenas |
cesarcardenas981@gmail.com |
Myself |
Des moines |
Polk |
Iowa |
Cesar cardenas |
Cesar cardenas gonzalez |
Signed |
70 |
2020-02-19 19:30 |
Anonymous (not verified) |
173.25.39.58 |
Central Iowa Portable Welding |
Limited Liability Company |
708 S Main St. Woodward Ia, 50276 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
Eric Lendt |
Eric@weldiowa.com |
Woodward |
America |
IA |
Chris Lendt |
Central Iowa Portable Welding |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Central Iowa Portable Welding |
Eric@weldiowa.com |
Himself |
woodward |
American |
IA |
Central Iowa Portable Welding |
Central Iowa Portable Welding |
Signed |
447 |
2021-03-24 14:09 |
Anonymous (not verified) |
208.90.15.53 |
Gabe Saenz, LLC |
Limited Liability Company |
PO Box 53 Humboldt, IA 50548 |
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. |
2021-03-24 |
Gabriel Saenz |
gsaenzh@gmail.com |
Humboldt |
Humboldt |
Iowa |
Lance DeWinter |
Cathy Schipull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gabriel Saenz |
gsaenzh@gmail.com |
Owner |
Humboldt |
Humboldt |
Iowa |
Lance DeWinter |
Cathy Schipull |
Signed |
919 |
2022-02-16 21:13 |
Anonymous (not verified) |
208.126.203.31 |
K & D Land Improvement, LLC |
Limited Liability Company |
2719 270th Street, Lehigh, Iowa 50557 |
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. |
2022-02-16 |
Daniel Hansen |
dhansen@lvcta.com |
Lehigh |
Webster |
Iowa |
Karen Hansen |
Cathy Mickelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Hansen |
dhansen@lvcta.com |
Member |
Lehigh |
Webster |
Iowa |
Karen Hansen |
Cathy Mickelson |
Signed |
983 |
2022-03-18 11:02 |
Anonymous (not verified) |
66.180.9.84 |
Gary Runyon |
Proprietorship |
101 Harris St Ste 1 Hastings, IA 51540 |
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. |
2022-03-18 |
Gary Runyon |
garyrunyon26@gmail.com |
Henderson |
Mills |
Iowa |
Gary Runyon |
Cathy Mardesen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Runyon |
garyrunyon26@gmail.com |
owner |
Henderson |
Mills |
Iowa |
Gary Runyon |
Cathy Mardesen |
Signed |
1999 |
2024-01-25 16:57 |
Anonymous (not verified) |
94.188.205.177 |
Nicholas Schaff |
Limited Liability Company |
6934 rolling ridge ct sw cedar rapids Iowa 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. |
2024-01-25 |
Nicholas Schaff |
schaff.lawncare@gmail.com |
cedar rapids |
linn |
iowa |
Brian Zeller |
Cassie Schaff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas schaff |
schaff.lawncare@gmail.com |
Same person |
cedar rapids |
iowa |
iowa |
Brian zeller |
cassie schaff |
Signed |
1781 |
2023-08-03 21:23 |
Anonymous (not verified) |
94.188.205.166 |
Ron Peiffer Machine |
Limited Liability Company |
139 S 1st St Harpers Ferry, Ia 52146 |
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. |
2023-08-03 |
Ron Peiffer |
ron@rpeiffer.com |
Harpers Ferry |
Allamakee |
Iowa |
Marie Burington |
Cassie Bakke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Peiffer |
ron@rpeiffer.com |
myself- SOLE PROPRIETOR |
Harpers Ferry |
Allamakee |
Iowa |
Marie Burington |
Cassie Bakke |
Signed |
174 |
2020-06-05 15:10 |
Anonymous (not verified) |
98.21.202.208 |
Bloomfield Properties LLC |
Limited Liability Company |
206 Weaver Road, Bloomfield, IA 52537 |
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. |
2020-06-05 |
Terri Roberts |
terri_roberts58@yahoo.com |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terri Roberts |
terri_roberts58@yahoo.com |
shareholder |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
175 |
2020-06-05 15:14 |
Anonymous (not verified) |
98.21.202.208 |
Bloomfield Properties LLC |
Limited Liability Company |
206 Weaver Road, Bloomfield, IA 52537 |
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. |
2020-06-05 |
Dave Lawrence |
terri_roberts58@yahoo.com |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terri Roberts |
terri_roberts58@yahoo.com |
shareholder |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
38 |
2020-01-18 12:15 |
Anonymous (not verified) |
206.109.174.199 |
BJS Frenchies, LLC |
Limited Liability Company |
20081 Highway J 46 Centerville Iowa 52544 |
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. |
2020-01-06 |
J. Jamie Tracy |
jamiespuppies@yahoo.com |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce E Tracy |
jamiespuppies@yahoo.com |
Husband and Co Owner |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |