1107 |
2022-05-16 15:28 |
Anonymous (not verified) |
64.33.230.163 |
hangar 8 spray service |
Limited Liability Company |
1626 airport 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. |
2022-05-16 |
jed douglas hansen |
hangar.8@hotmail.com |
Clark |
South Dakota |
United States |
jed douglas hansen |
jed douglas hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jed douglas hansen |
hangar.8@hotmail.com |
contract |
Clark |
South Dakota |
United States |
Jed Hansen |
Jed Hansen |
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 |
1114 |
2022-05-17 15:30 |
Anonymous (not verified) |
67.212.117.198 |
Busta Painting |
Limited Liability Company |
610 W 26th st #1 Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Evan Busta |
bustapainting@gmail.com |
Cedar Falls |
IA |
United States |
Tanner Heikens |
Garrett Burrack |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evan Busta |
bustapainting@gmail.com |
Self Employeed |
Cedar Falls |
IA |
United States |
Tanner Heikens |
Garrett Burrack |
Signed |
1132 |
2022-05-28 12:01 |
Anonymous (not verified) |
166.181.81.175 |
Kamp Trucking LLC |
Limited Liability Company |
3411 doris lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-28 |
Joseph Michael Kamp |
boss4z9@yahoo.com |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Michael Kamp |
boss4z9@yahoo.com |
same person. I am an owner operator |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
Signed |
1140 |
2022-06-02 21:20 |
Anonymous (not verified) |
167.142.38.107 |
BV Transport LLC |
Limited Liability Company |
3406 150th 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. |
2022-06-02 |
Brody Joseph Vaske |
Brody.vaske44@gmail.com |
Bancroft |
IA |
United States |
Ed Goche |
Kelly Deitering |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brody Vaske |
Brody.vaske44@gmail.com |
Self |
Bancroft |
IA |
United States |
Ed Goche |
Kelly Deitering |
Signed |
1143 |
2022-06-06 15:48 |
Anonymous (not verified) |
63.152.93.184 |
Adaptability Plus |
Limited Liability Company |
904 W 4th 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. |
2022-01-02 |
Timothy Combs |
tcombshd@gmail.com |
Cedar Falls |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Combs |
tcombshd@gmail.com |
none |
Cedar Falls |
Black Hawk |
Iowa |
Mark Moser |
Teresa Tjaden |
Signed |
1147 |
2022-06-08 11:29 |
Anonymous (not verified) |
67.55.184.250 |
Morgan Anderson |
Proprietorship |
23379 120th Ave, Mediapolis, IA 52637 |
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. |
2022-06-08 |
Morgan Duane Anderson |
morgananderson6.ma@gmail.com |
Mediapolis |
IA |
United States |
Kelly S Lanz |
Monte A Lanz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Morgan D. Anderson |
morgananderson6.ma@gmail.com |
sole proprietor |
Mediapolis |
Louisa |
Iowa |
Kelly Lanz |
Monte Lanz |
Signed |
1158 |
2022-06-17 06:34 |
Anonymous (not verified) |
97.125.255.177 |
Zach Ellis |
Proprietorship |
3013 Se Stoneridge St Grimes ia 50111 |
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. |
2022-06-17 |
Zachary Ellis |
zach2865@gmail.com |
Grimes |
IA |
United States |
Brittany Klien |
Kennedy Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Ellis |
zach2865@gmail.com |
Myself |
Grimes |
Polk |
Iowa |
Brittany Klien |
Kennedy Ellis |
Signed |
1170 |
2022-06-24 08:52 |
Anonymous (not verified) |
66.255.230.24 |
Anderson's Flying Service |
Proprietorship |
PO Box 127 Robbins, CA 95676 |
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. |
2022-06-24 |
Stephen Anderson |
steve@andersonsflying.com |
YUBA CITY |
CA |
United States |
Greg Foster |
Cliff Snelling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Anderson |
steve@andersonsflying.com |
Self |
YUBA CITY |
CA |
United States |
Greg Foster |
Cliff Snelling |
Signed |
1174 |
2022-06-28 07:53 |
Anonymous (not verified) |
70.39.7.208 |
SG Solid Grounds |
Proprietorship |
402 3rd Ave SE State Center Iowa 50247 |
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. |
2022-06-27 |
Stephen Graham |
sgsolidgrounds@gmail.com |
STATE CENTER |
IA |
United States |
Stacie Graha |
Paula Atkinson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Graham |
sgsolidgrounds@gmail.com |
Owner |
STATE CENTER |
IA |
United States |
Stacie Graham |
Paula Atkinson |
Signed |
1178 |
2022-07-05 12:02 |
Anonymous (not verified) |
172.58.122.51 |
Wright home restoration |
Limited Liability Company |
2914 South Union 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. |
2022-07-05 |
Matthew Wright |
wright.home.restoration@gmail.com |
Des Moines |
IA |
United States |
Jane wright |
Robert wright |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wright home restoration |
wright.home.restoration@gmail.com |
Myself |
Des Moines |
IA |
United States |
Jane wright |
Robert Wright |
Signed |
1182 |
2022-07-06 13:40 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW |
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. |
2022-02-11 |
Gilberto Vasquez (GV Construction LLC) |
Normambazquez@gmail.com |
Iowa City |
IA |
United States |
Pedro Pinto |
Rafael Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
gsaunders@beastconstructioncr.com |
Owner |
CEDAR RAPIDS |
IA |
United States |
Laura Saunders |
Joanie Lacayo |
Signed |
1192 |
2022-07-07 21:15 |
Anonymous (not verified) |
174.242.226.74 |
Quelland Flooring |
Limited Liability Company |
P.O. Box 5, 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. |
2022-07-07 |
Jared Tyler Quelland |
Jquelland@gmail.com |
Van Meter |
IA |
United States |
Denise Walters |
Madison Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Tyler Quelland |
Jquelland@gmail.com |
Self |
Van Meter |
IA |
United States |
Denise Walters |
Madison Mileer |
Signed |
1199 |
2022-07-11 16:28 |
Anonymous (not verified) |
166.222.225.181 |
Myriad Global Business Solutions |
Proprietorship |
8016 Brooks Loop |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-11 |
James Eugene Hasquet, III |
Jay.Hasquet@Outlook.com |
Spearfish |
South Dakota |
United States |
Kent Orfield |
Kyle Padget |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Eugene Hasquet, III |
Jay.Hasquet@Outlook.com |
Self |
Spearfish |
South Dakota |
United States |
Kent Orfield |
Kyle Padget |
Signed |
1204 |
2022-07-14 11:59 |
Anonymous (not verified) |
107.1.252.41 |
International Drywall LLC. |
Limited Liability Company |
108 N 4th 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. |
2022-07-14 |
Victoria G Cervantes |
vic8.cervantes@gmail.com |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victoria G Cervantes |
Vic8.cervantes@gmail.com |
Self |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
1209 |
2022-07-17 16:41 |
Anonymous (not verified) |
166.181.86.161 |
JustbelieveCreationsllc |
Limited Liability Company |
104 East Chestnut 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. |
2022-07-17 |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Garnavillo |
IA |
United States |
Eric Jarman |
Jean brandt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Myself |
Garnavillo |
IA |
United States |
Eric jarman |
Jean brandt |
Signed |
1213 |
2022-07-19 14:00 |
Anonymous (not verified) |
198.14.220.143 |
VLG Build & Remodle LLC |
Limited Liability Partnership |
45547 State HWY 14 Chariton, IA 50049 |
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. |
2022-07-19 |
Vladimir Golosinskiy |
VLGCONSTRUCTION@YAHOO.COM |
Chariton |
IA |
United States |
Vladimir Golosinskiy |
Vladimir Golosinskiy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LILIA GOLOSINSKIY |
VLGCONSTRUCTION@YAHOO.COM |
Wife |
CHARITON |
Iowa |
United States |
LILIA GOLOSINSKIY |
LILIA GOLOSINSKIY |
Signed |
1217 |
2022-07-21 06:51 |
Anonymous (not verified) |
209.152.88.53 |
Bullard Accounting Services, LLC |
Limited Liability Company |
4519 Scouts View Dr, Central City, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Michael Bullard |
mikeandkarenbullard@gmail.com |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Bullard |
mikeandkarenbullard@gmail.com |
President of Company |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
1219 |
2022-07-21 12:39 |
Anonymous (not verified) |
98.22.2.115 |
Keeling Services |
Proprietorship |
3190 SE 64th St, pleasant Hill, IA 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Josh keeling |
Joshuakeeling110@gmail.com |
Pleasant Hill |
Iowa |
United States |
Kali Keeling |
Matthew Keeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Bond |
mbond@leaffilter.com |
Regional sales manager |
Grimes |
Polk |
Iowa |
Kali Keeling |
Matthew Keeling |
Signed |
1222 |
2022-07-21 16:01 |
Anonymous (not verified) |
66.129.208.246 |
James J Stallman |
Proprietorship |
190 BLUFF DR, Fairfax, IA 52228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
James J Stallman |
stallmanjim@aol.com |
FAIRFAX |
IA |
United States |
James J Stallman |
James J Stallman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lundahl, Hatt, Austad Tax Services Inc |
NN@LHAtax.com |
President |
Marion |
Linn |
IA |
James J Stallman |
James J Stallman |
Signed |
1223 |
2022-07-22 15:14 |
Anonymous (not verified) |
167.142.255.81 |
HomeOwner's Helper LLC |
Limited Liability Company |
111 4th Ave, Underwood, IA 51576 |
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. |
2022-07-22 |
Bradley W Syndergaard |
mrslouie8@yahoo.com |
UNDERWOOD |
Iowa |
United States |
Stacy L Louison |
Brent C Louison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bradley W Syndergaard |
mrslouie8@yahoo.com |
Self |
UNDERWOOD |
Iowa |
United States |
Stacy L Louison |
Brent C Louison |
Signed |
1228 |
2022-07-26 10:06 |
Anonymous (not verified) |
173.23.93.3 |
Gaytan Framing LLC |
Limited Liability Company |
2418 East 37th Court |
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. |
2022-07-26 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
United States |
CARLA C. GAYTAN |
Juan Franco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan |
jose1988.jg8@gmail.com |
self |
Des Moines |
IA |
United States |
CARLA C. GAYTAN |
Juan franco |
Signed |
1230 |
2022-07-27 08:59 |
Anonymous (not verified) |
108.217.146.87 |
Hunter Flying Service |
Limited Liability Company |
PO Box 215 Hunter, AR 72074 |
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. |
2022-07-27 |
Lynn Cary |
hunterflying@att.net |
Hunter |
Woodruff |
United States |
Karen Gifford |
Jason White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lynn Cary |
hunterflying@att.net |
Owner |
Hunter |
AR |
United States |
Karen Gifford |
Jason White |
Signed |
1235 |
2022-08-01 17:22 |
Anonymous (not verified) |
129.222.1.151 |
KRG Gutters |
Limited Liability Company |
20376 Whiskey Rdg Ottumwa, Ia 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-01 |
Robert M Galey |
rsgaley24@yahoo.com |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Galey |
rsgaley24@gmail.com |
Self |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
1237 |
2022-08-01 22:40 |
Anonymous (not verified) |
50.80.97.239 |
Andy Fiala |
Proprietorship |
1628 34th St. NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-01 |
Andy W Fiala |
fialaandy1@gmail.com |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andy W Fiala |
fialaandy1@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
1241 |
2022-08-03 10:56 |
Anonymous (not verified) |
72.169.80.108 |
Landon Henriksen |
Proprietorship |
35374 GARDEN 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-03 |
LANDON HENRIKSEN |
HENRIKSENLK@AOL.COM |
Edgewood |
IA |
United States |
LANDON HENRIKSEN |
LANDON HENRIKSEN |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
LANDON HENRIKSEN |
HENRIKSENLK@AOL.COM |
Same |
Edgewood |
IA |
United States |
Scott Johnson |
Josh lafond |
Signed |
1256 |
2022-08-15 13:22 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-08 |
Richard Miller |
rmiller0574@gmail.com |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1257 |
2022-08-15 13:27 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-15 |
Amanda Carol Loeffelholz |
evansamanda300@yahoo.com |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1258 |
2022-08-15 13:30 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-15 |
George Anthony Loeffelholz |
tobby.loeffelholz@gmail.com |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
1264 |
2022-08-16 21:22 |
Anonymous (not verified) |
50.82.84.19 |
Nogotta Trucking LLC |
Limited Liability Company |
16617 Wilden Dr, Clive IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-16 |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Managing Member |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
1280 |
2022-08-22 15:48 |
Anonymous (not verified) |
104.222.83.187 |
Cabinet Kulture LLC |
Limited Liability Company |
927 N. West St. Carroll, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Jordan Ellis |
cabinetkulture@gmail.com |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cabinet Kulture LLC |
cabinetkulture@gmail.com |
Same person |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
1282 |
2022-08-25 06:51 |
Anonymous (not verified) |
63.240.136.241 |
River City Property Services LLC. |
Limited Liability Company |
1936 9th 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. |
2022-08-25 |
Brandon Smith |
RiverCityPropertyServices@outlook.com |
Camanche |
Iowa |
United States |
Sarah Smith |
MIke Burmahl |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Smith |
RiverCityPropertyServices@outlook.com |
Partner |
Camanche |
Iowa |
United States |
Sarah Smith |
MIke Burmahl |
Signed |
1291 |
2022-09-02 13:24 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
Limited Liability Company |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-02 |
Nicole Keck |
niccikeckllc@gmail.com |
Iowa City |
Iowa |
United States |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
1292 |
2022-09-02 13:26 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
Limited Liability Company |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-02 |
Benjamin Darbro |
darbrob@gmail.com |
Iowa City |
Iowa |
United States |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
1294 |
2022-09-04 18:09 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
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. |
2022-09-04 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
1295 |
2022-09-05 20:39 |
Anonymous (not verified) |
173.30.59.248 |
Guide LLC |
Limited Liability Company |
1655 Ashton Place, 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. |
2022-09-05 |
Braydon Fisher |
braydonfisher28@gmail.com |
Dubuque |
IA |
United States |
Conner Cole |
Alec Kolander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Braydon Fisher |
braydonfisher28@gmail.com |
Owner |
Dubuque |
IA |
United States |
Conner Cole |
Alex Kolander |
Signed |
1308 |
2022-09-14 21:25 |
Anonymous (not verified) |
166.196.110.63 |
Anhalt Trucking |
Limited Liability Company |
Canby MN |
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. |
2022-09-13 |
Jordan J Anhalt |
anhalt.trucking@gmail.com |
Canby |
MN |
United States |
Ashley Anhalt |
Jace Anhalt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan J Anhalt |
anhalt.trucking@gmail.com |
Same |
Canby |
MN |
United States |
Ashley Anhalt |
Jace Anhalt |
Signed |
1333 |
2022-10-13 14:01 |
Anonymous (not verified) |
174.192.85.141 |
Terry Smith |
Proprietorship |
1028 14th Avenue Fulton il |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-14 |
Terry Smith |
terry1270smith@gmail.com |
Fulton |
IL |
United States |
Angela Smith |
Tracey Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Smith |
terry1270smith@gmail.com |
Wife |
Fulton |
IL |
United States |
Angie Smith |
Tracey smith |
Signed |
1336 |
2022-10-17 12:42 |
Anonymous (not verified) |
63.152.97.11 |
Adaptability Plus Llc |
Limited Liability Company |
904 W 4th Street, Waterloo Iowa 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. |
2022-10-17 |
Timothy Combs |
timcombs@afiliowa.org |
Waterloo |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Combs |
timcombs@afiliowa.org |
none |
Waterloo |
Iowa |
United States |
Mark Moser |
Teresa Tjaden |
Signed |
1341 |
2022-10-23 14:31 |
Anonymous (not verified) |
97.127.255.147 |
Traver Home Improvement |
Limited Liability Company |
14150 110 th Ave. Davenport, IA 52804 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-24 |
Barry S Traver |
traverhomeimprovement@gmail.com |
Davenport |
IA |
United States |
Denise Baughman |
Joni Bryant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barry S Traver |
traverhomeimprovement@gmail.com |
self |
Davenport |
IA |
United States |
Denise Baughman |
Joni Bryant |
Signed |
1347 |
2022-10-26 14:42 |
Anonymous (not verified) |
173.21.223.66 |
Mid American Roofing |
Limited Liability Company |
811 8th St Kalona IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-26 |
Josiah Hoyt |
midamericanroofing@gmail.com |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josiah Hoyt |
josiahhoyt@gmail.com |
Owner |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
1349 |
2022-10-28 12:37 |
Anonymous (not verified) |
173.26.153.59 |
spotlight drywall |
Proprietorship |
1001 7th 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. |
2022-06-01 |
paul woods |
spotlight.2008@hotmail.com |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
thuy do |
spotlight.2008@hotmail.com |
bookeeper |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |
1350 |
2022-10-31 10:42 |
Anonymous (not verified) |
108.160.48.9 |
gaes trucking |
Proprietorship |
84642 Dun Rd Norfolk, NE 68701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
SHANE GAES |
scgaes@icloud.com |
Norfolk |
NE |
United States |
Bill Rich |
Ben Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
shane gaes |
scgaes@icloud.com |
self |
norfolk |
pierce county nebraska |
nebraska |
Bill Rich |
Ben Becker |
Signed |
1352 |
2022-10-31 19:35 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping INC |
Limited Liability Company |
5235 JENNIFER 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. |
2022-10-31 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
NIC HUTCHINSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
SELF |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
NIC HUTCHINSON |
Signed |
1353 |
2022-10-31 21:35 |
Anonymous (not verified) |
50.82.84.225 |
Jerry Bassett |
Proprietorship |
108 NE 22 Cr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
Jerry Bassett |
JerryDebBassett@aol.com |
GRIMES |
IA |
United States |
Deb Bassett |
Jerry Bassett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Bassett |
JerryDebBassett@aol.com |
Self |
Grimes |
Polk |
Iowa |
Deb Bassett |
Jerry Bassett |
Signed |
1364 |
2022-11-09 09:57 |
Anonymous (not verified) |
50.80.120.38 |
Egl Enterprises, Inc. |
Proprietorship |
314 2ND AVE NW |
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. |
2022-11-09 |
EUGENE G LARUE |
egl.enterprises.inc@gmail.com |
HAMPTON |
IA |
United States |
stephanie hofer |
aryel laRue |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
EUGENE G LARUE |
egl.enterprises.inc@gmail.com |
self |
HAMPTON |
IA |
United States |
stephanie hofer |
aryel laRue |
Signed |
1366 |
2022-11-10 09:33 |
Anonymous (not verified) |
172.58.87.232 |
Blackstone Handy Services, LLC |
Limited Liability Company |
1807 B Avenue Northeast |
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. |
2022-11-10 |
jovan walton |
blackstonehandyservices@gmail.com |
Cedar Rapids |
IA |
United States |
Mekaylah K. Stevens |
Dominique T. Walton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jovan walton |
blackstonehandyservices@gmail.com |
Self |
Cedar Rapids |
Linn |
United States |
Mekaylah K. Stevens |
Dominique T. Walron |
Signed |
1370 |
2022-11-13 19:49 |
Anonymous (not verified) |
174.213.144.30 |
Iowa’s Gutter Specialist |
Limited Liability Company |
1390 Lark 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. |
2022-10-21 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Patricia Reynolds |
Heather Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Patricia Marie Reynolds |
Heather Marie Halverson |
Signed |
1371 |
2022-11-14 10:55 |
Anonymous (not verified) |
166.181.86.95 |
Dean Abramczak |
Proprietorship |
524 Nodaway Dr center Point Iowa 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-16 |
Dean Abramczak |
gabramczak@gmail.com |
Center Point |
IA |
United States |
Brenda Oconner |
Kenny McGraw |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dean Abramczak |
gabramczak@gmail.com |
I am the only employee I own the company |
Center Point |
IA |
United States |
Brenda Oconnner |
Kenny McGraw |
Signed |
1372 |
2022-11-14 20:36 |
Anonymous (not verified) |
198.14.213.147 |
Accurate Grading, LLC |
Limited Liability Company |
1417 290th St Macksburg, IA 50155 |
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. |
2022-11-14 |
Dustin A McVay |
dustin0980@gmail.com |
Macksburg |
IA |
United States |
Dustin A McVay |
Angela D McVay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin A McVay |
dustin0980@gmail.com |
Owner |
Macksburg |
United States |
Iowa |
Dustin A McVay |
Angela D McVay |
Signed |