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 |
1269 |
2022-08-18 16:17 |
Anonymous (not verified) |
67.55.174.140 |
Roberts Compliance Services, LLC |
Limited Liability Company |
405 Hilltop Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-18 |
Daniel Roberts |
dan@robertscompliance.com |
Stanton |
Montgomery |
IA |
Robert Schenck |
Pier Osweiler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Roberts |
dan@robertscompliance.com |
self |
Stanton |
Montgomery |
IA |
Robert Schenck |
Pier Osweiler |
Signed |
2054 |
2024-02-23 10:33 |
Anonymous (not verified) |
94.188.205.175 |
Overgrown Lawn Care & Clean-Up LLC |
Limited Liability Company |
860 Main St. Stanhope, Iowa 50246 |
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. |
2024-02-23 |
Shawn David King |
shawndavidking@yahoo.com |
Stanhope |
Hamilton |
Iowa |
Michael Roland King |
Chrisella Ann King |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn David King |
overgrownlawn@yahoo.com |
Is Owner |
Stanhope |
Hamilton |
Iowa |
Michael Roland King |
Chrisella Ann King |
Signed |
1761 |
2023-07-26 08:40 |
Anonymous (not verified) |
94.188.207.224 |
Gerk Trucking |
Proprietorship |
401 W college, Stacyville, IA 50476 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-26 |
Charles W. Gerk |
cwgerk@gmail.com |
Stacyville |
Mitchell |
iowa |
Jeannie Lemke |
Robin Tabbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles W. Gerk |
cwgerk@gmail.com |
Same |
Stacyville |
Mitchell |
Iowa |
Jeannie Lemke |
Robin Tabbert |
Signed |
291 |
2020-10-25 11:06 |
Anonymous (not verified) |
208.126.69.94 |
self-employed |
Proprietorship |
PO Box 15, 430 E. Iowa 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. |
2022-10-25 |
Steven Fisher |
fishersjk@gmail.com |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Fisher |
fishersjk@gmail.com |
same person |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
165 |
2020-05-26 14:12 |
Anonymous (not verified) |
216.51.228.161 |
Arbor Way All About Trees |
Limited Liability Company |
417 Howard St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-26 |
Nicholas Plumski |
arborway14@gmail.com |
Saint Anthony |
Marshall |
Iowa |
Michael Richards |
Nicole Plumski |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Plumski |
arborway14@gmail.com |
Owner |
St. Anthony |
Marshall |
IA |
Michael Richards |
Nicole Plumski |
Signed |
1355 |
2022-11-01 11:06 |
Anonymous (not verified) |
23.252.149.120 |
Randy J. Hackenmiller dba Hackenmiller Trucking |
Proprietorship |
606 Grain Millers Dr. PO Box 125, St. Ansgar, IA 50472-0125 |
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. |
2022-11-01 |
Randy J. Hackenmiller |
randhack@myomnitel.com |
St. Ansgar |
Mitchell |
Iowa |
Kent A. Wilder |
Rebecca L. Dobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy J. Hackenmiller |
randhack@myomnitel.com |
Self |
St. Ansgar |
Mitchell |
Iowa |
Kent A. Wilder |
Rebecca L. Dobson |
Signed |
306 |
2020-11-02 20:31 |
Anonymous (not verified) |
208.126.30.236 |
foust lawn care llc |
Limited Liability Company |
2999 st charles rd st charles ia 50240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-05 |
stephen howard foust |
shfoust53@gmail.com |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
stephen howard foust |
shfoust53@gmail.com |
self |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
2016 |
2024-02-01 09:20 |
Anonymous (not verified) |
94.188.207.225 |
Imperium Outdoor Solutions |
Proprietorship |
114 W Clanton St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-01 |
Austin Beener |
abeener033@gmail.com |
St Charles |
IA |
United States |
Austin Beener |
Austin Beener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Beener |
abeener033@gmail.com |
Operator |
St Charles |
IA |
United States |
Austin Beener |
Austin Beener |
Signed |
431 |
2021-03-10 14:41 |
Anonymous (not verified) |
66.188.136.150 |
Brad Donovan |
Proprietorship |
1105 N 5th. Springfield, IL 62702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
Brad Donovan |
braddonovan40@gmail.com |
Springfield |
Sangamon |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brad Donovan |
braddonovan40@gmail.com |
Same |
Springfield |
Sangamon |
IL |
Russell Masartis |
Shuree Behr |
Signed |
556 |
2021-07-07 09:16 |
Anonymous (not verified) |
66.188.136.150 |
William Campbell |
Proprietorship |
159 Friendly Blvd. Springfield, IL 62707 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-06 |
William Campbell |
kschumacher@tricorinsurance.com |
Springfield |
Sangamon |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Campbell |
kschumacher@tricorinsurance.com |
Same |
Springfield |
Sangamon |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
745 |
2021-11-11 15:24 |
Anonymous (not verified) |
72.13.16.172 |
SCHLECHT TRUCKING LLC |
Limited Liability Company |
107 SOUTH 1ST 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. |
2019-11-18 |
SCHLECHT TRUCKING LLC |
dave@allseasonstrucking.com |
SPRINGBROOK |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SCHLECHT TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
SPRINGBROOK |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
736 |
2021-11-11 14:26 |
Anonymous (not verified) |
72.13.16.172 |
All Seasons Trucking Inc |
Proprietorship |
S11689 CTY RD G |
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. |
2019-11-18 |
FARGEN TRUCKING |
dave@allseasonstrucking.com |
SPRING GREEN |
SAUK |
WI |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
FARGEN TRUCKING |
DAVE@ALLSEASONSTRUCKING.COM |
PRESIDENT |
SPRING GREEN |
SAUK |
WI |
Dave Neuwohner |
BEN MOYER |
Signed |
344 |
2020-12-28 11:31 |
Anonymous (not verified) |
173.31.147.225 |
JEFFREY GOETZINGER |
Proprietorship |
2112 ITHACA AVE SPIRIT LAKE IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-22 |
JEFFREY GOETZINGER |
WALKERINSURANCE@MCHSI.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JEFFREY GOETZINGER |
WALKERINSURANCE@MCHSI.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
357 |
2021-01-12 09:56 |
Anonymous (not verified) |
173.31.147.225 |
SKYLAR INGRAHAM |
Proprietorship |
903 9TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-12 |
SKYLAR INGRAHAM |
18SINGRAHA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SKYLAR INGRAHAM |
18SINGRAHA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
364 |
2021-01-14 13:46 |
Anonymous (not verified) |
173.31.147.225 |
JMAHER LLC |
Limited Liability Company |
907 4TH 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. |
2021-01-14 |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
475 |
2021-04-13 19:19 |
Anonymous (not verified) |
173.31.147.225 |
COAST TO COAST MILLWRIGHT LLC |
Limited Liability Company |
2909 HWY 71 AND 9 |
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. |
2021-04-05 |
JANIE CANTU |
JOEL@WALKERINSURANCEIA.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JANIE CANTU |
janiecantu433@outlook.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
476 |
2021-04-13 19:23 |
Anonymous (not verified) |
173.31.147.225 |
COAST TO COAST MILLWRIGHT LLC |
Limited Liability Company |
2909 HWY 71 AND 9 SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-04-05 |
ADALBERTO CANTU |
JOEL@WALKERINSURANCEIA.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
ADALBERTO CANTU |
janiecantu433@outlook.com |
SELF-MEMBER |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
498 |
2021-04-27 12:54 |
Anonymous (not verified) |
173.31.147.225 |
TYREL KINKADE DBA: KINKADE CONSTRUCTION |
Proprietorship |
2289 165TH ST UNIT 10D |
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. |
2021-04-21 |
TYREL KINKADE |
hogtyd97@yahoo.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL KINKADE |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
636 |
2021-09-10 14:56 |
Anonymous (not verified) |
173.19.179.111 |
SHANNON SUNDINE |
Proprietorship |
513 16TH ST SPIRIT LAKE IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
SHANNON SUNDINE |
SPSUNDINE@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNG WIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHANNON SUNDINE |
SPSUNDINE@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
766 |
2021-11-22 16:19 |
Anonymous (not verified) |
63.229.189.35 |
Tribal Tile, LLC |
Limited Liability Company |
1402 Ithaca Ave, Spirit Lake, IA 51360 |
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. |
2021-11-22 |
Josh Loerzel |
joshloerzel@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Loerzel |
joshloerzel@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
IA |
Abigail Miles |
Alex Miles |
Signed |
767 |
2021-11-22 16:42 |
Anonymous (not verified) |
63.229.189.35 |
Lakes Custom Bath |
Proprietorship |
3721 Ithaca Avenue, Spirit Lake IA 51360 |
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. |
2021-11-22 |
Rick Dykshoorn |
abigail@rickmilesartisans.com |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Dykshoorn |
abigail@rickmilesartisans.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
768 |
2021-11-22 16:53 |
Anonymous (not verified) |
63.229.189.35 |
Jeff Luchtel Painting |
Proprietorship |
PO Box 225, Milford, IA 51351-0225 |
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. |
2021-11-22 |
Jeff Luchtel |
jluchtel@gmail.com |
Milford |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Luchtel |
abigail@rickmilesartisans.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
769 |
2021-11-22 17:13 |
Anonymous (not verified) |
63.229.189.35 |
Jeff Johnson |
Proprietorship |
3114 Keokuk Ave, Spirit Lake, IA 51360 |
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. |
2021-11-22 |
Jeff Johnson |
juliejeff1994@yahoo.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Johnson |
abigail@rickmilesartisans.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
800 |
2021-12-15 16:50 |
Anonymous (not verified) |
63.229.189.35 |
CT Home Services |
Limited Liability Company |
706 Jackson Avenue, Spirit lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-15 |
Mike Oolman |
mikecthome@gmail.com |
Spirit lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Oolman |
mikecthome@gmail.com |
Self |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
1126 |
2022-05-25 12:06 |
Anonymous (not verified) |
63.229.189.35 |
Frame 2 Finish LLC |
Limited Liability Company |
25620 164th St Spirit lake, IA51360 |
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. |
2022-05-05 |
Chris Miller |
frame2finish3550@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Miller |
frame2finish3550@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
1476 |
2023-02-22 12:23 |
Anonymous (not verified) |
94.188.205.174 |
KARL INGWERSEN |
Proprietorship |
2716 FRANCIS SITES DR SPIRIT LAKE, IA 51360 |
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. |
2023-02-22 |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKSINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1626 |
2023-05-05 11:16 |
Anonymous (not verified) |
94.188.205.166 |
I HAWK BUILDERS LLC |
Limited Liability Company |
1417 INDIAN HILLS DR SPIRIT LAKE, IA 51360 |
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. |
2023-05-05 |
BEN BRANT |
babrant99@yahoo.com |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BEN BRANT |
joel@walkerinsuranceia.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1850 |
2023-09-20 16:28 |
Anonymous (not verified) |
94.188.207.225 |
JB DOCK SERVICE |
Limited Liability Company |
1313 34TH ST SPIRIT LAKE, IA 51360 |
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. |
2023-09-20 |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1867 |
2023-10-16 12:34 |
Anonymous (not verified) |
94.188.205.176 |
North Bay Dock Service |
Proprietorship |
PO Box 374, Spirit Lake, IA 51360 |
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. |
2023-10-16 |
Donald L. Johnson, Jr. |
djtjaj@outlook.com |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Teresa Johnson |
djtjaj@outlook.com |
bookkeeper |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
1868 |
2023-10-16 12:36 |
Anonymous (not verified) |
94.188.205.177 |
North Bay Dock Service, LLC |
Limited Liability Company |
PO Box 374, Spirit Lake, IA 51360 |
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. |
2023-10-16 |
Teresa A. JOhnson |
NBDSLLC@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Teresa Johnson |
NBDSLLC@gmail.com |
Manager |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
1977 |
2024-01-05 13:25 |
Anonymous (not verified) |
94.188.207.228 |
BOYOK BUILDS, LLC |
Limited Liability Company |
25395 140TH ST, SPIRIT LAKE, IA 51360 |
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. |
2024-01-04 |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1978 |
2024-01-08 13:28 |
Anonymous (not verified) |
94.188.205.167 |
TYREL GIBSON |
Proprietorship |
2004 CHICAGO AVE SPIRIT LAKE, IA 51360 |
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. |
2024-01-08 |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2115 |
2024-03-26 14:53 |
Anonymous (not verified) |
94.188.207.223 |
DICKINSON COUNTY CLEANING AND MAINTENANCE, LLC |
Limited Liability Company |
414 19TH ST PO BOX 182 SPIRIT LAKE, IA 51360 |
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. |
2024-03-26 |
LISA ARROWOOD |
lisa.arrowood1126@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LISA ARROWOOD |
lisa.arrowood1126@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
763 |
2021-11-22 12:32 |
Anonymous (not verified) |
63.229.189.35 |
Adam Dotson Tiling |
Proprietorship |
324 E 14th Street, 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. |
2021-11-22 |
Adam Dotson |
adamdotson1975@gmail.com |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Dotson |
adamdotson1975@gmail.com |
Self |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
770 |
2021-11-22 18:17 |
Anonymous (not verified) |
192.82.97.13 |
Paul Wire |
Proprietorship |
1005 25th Street SW, 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. |
2021-11-22 |
Paul Wire |
gizzmochee@gmail.com |
Spencer |
Clay |
IA |
Lori Wire |
Abigail Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Wire |
gizzmochee@gmail.com |
Self |
Spencer |
Clay |
IA |
Lori Wire |
Abigail Miles |
Signed |
772 |
2021-11-23 10:13 |
Anonymous (not verified) |
63.229.189.35 |
Hubbards Cupboards |
Proprietorship |
713 2nd Ave SW, Spencer, IA 51301-5603 |
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. |
2021-11-23 |
James Hubbard |
abigail@rickmilesartisans.com |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Hubbard |
abigail@rickmilesartisans.com |
Self |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
1306 |
2022-09-13 15:50 |
Anonymous (not verified) |
96.31.1.206 |
LUCIO PAINTING |
Proprietorship |
818 W 4TH ST 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. |
2022-09-06 |
LUCIO PENA |
joel@walkerinsuranceia.com |
SPENCER |
CLAY |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LUCIO PENA |
joel@walkerinsuranceia.com |
SELF |
SPENCER |
CLAY |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
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 |
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 |
1856 |
2023-09-29 13:18 |
Anonymous (not verified) |
94.188.205.166 |
MUESSIGMANN ENTERTAINMENT LLC |
Limited Liability Company |
906 2ND AVE SE 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. |
2023-09-27 |
JON MUESSIGMANN |
MUESSIGMANNENT@GMAIL.COM |
SPENCER |
CLAY |
Iowa |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JON MUESSIGMANN |
MUESSIGMANNENT@GMAIL.COM |
SELF |
SPENCER |
CLAY |
Iowa |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
2030 |
2024-02-07 10:10 |
Anonymous (not verified) |
94.188.207.227 |
Jason Jacobs |
Proprietorship |
115 West 7th St., Suite 1W, 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. |
2024-02-07 |
Jason Jacobs |
jason.jacobs@thrivent.com |
Spencer |
Clay |
Iowa |
Brad Bernardy |
Emily Jacobs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Jacobs |
jason.jacobs@thrivent.com |
Self |
Spencer |
Clay |
Iowa |
Brad Bernardy |
Emily Jacobs |
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 |
287 |
2020-10-21 18:35 |
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 |
Gary George Bilyeu |
garygb1990@gmail.com |
Sparta |
Christian |
Missouri |
Daniel Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary George Bilyeu |
garygb1990@gmail.com |
Owner |
Sparta |
Christian |
Missouri |
Chad Anthony Charles |
Daniel Bilyeu |
Signed |
1509 |
2023-03-09 10:39 |
Anonymous (not verified) |
94.188.207.227 |
Andres Barboza |
Limited Liability Company |
329 West 31 St South Sioux city ne 68776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-09 |
Andres Barboza |
barboza79@yahoo.com |
South Sioux City |
Nebraska |
United States |
Jaime Gutierrez |
Gerardo ibarra |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andres Barboza |
barboza79@yahoo.com |
Owner |
South Sioux City |
Nebraska |
United States |
Jaime Gutierrez |
Gerardo ibarra |
Signed |
716 |
2021-11-05 13:22 |
Anonymous (not verified) |
209.252.172.87 |
Rick Clifford Clifford Custom Tile & Flooring |
Proprietorship |
1563 Palmer Ct NE, Solon, IA 52333 |
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. |
2020-09-24 |
Rick Clifford |
cliffordcustomtile@gmail.com |
Solon |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Clifford Clifford Custom Tile & Flooring |
cliffordcustomtile@gmail.com |
Self Employed |
Solon |
Johnson |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1153 |
2022-06-13 16:22 |
Anonymous (not verified) |
216.9.166.5 |
Ronald B Blakley |
Proprietorship |
2001 St Bridgets Rd NE, Solon IA 52333 |
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 |
Ronald B Blakley |
sanjahunt@gmail.com |
Solon |
Johnson |
Iowa |
Scott G Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald B Blakley |
Sanjahunt@gmail.com |
Owner |
Solon |
Johnson |
Iowa |
Scott G Freeman |
Dyan Kriener |
Signed |
1365 |
2022-11-09 15:42 |
Anonymous (not verified) |
173.189.165.11 |
Todd Nelson DBA: TSTR Custom Woodworking |
Proprietorship |
625 West Sovers St, Solon, IA 52333 |
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 |
Todd Nelson |
tstr4040@gmail.com |
Solon |
Johnson |
Iowa |
Jeff Bair-Agent |
Ryan Hajek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Nelson |
tstr4040@gmail.com |
Owner/Manager |
Solon |
Johnson |
IA |
Jeff Bair |
Ryan Hajek |
Signed |
1635 |
2023-05-10 07:25 |
Anonymous (not verified) |
94.188.205.166 |
Chris Hay |
Proprietorship |
4911 Sutliff Rd Solon, IA 52333 |
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. |
2023-05-10 |
Christopher A Hay |
hay2u2@windstream.net |
Solon |
Johnson |
Iowa |
Brad Bower |
Kirk Strunk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Hay |
hay2u2@windstream.net |
Self |
Solon |
Johnson |
Iowa |
Brad Bower |
Kirk Strunk |
Signed |
1913 |
2023-11-20 13:48 |
Anonymous (not verified) |
94.188.205.167 |
KWF SALES INC |
Proprietorship |
216 WINDFLOWER LANE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-20 |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SOLON |
Iowa |
Iowa |
ZACH GRANT |
TOM SIMPSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SELF |
SOLON |
IA |
IA |
ZACH GRANT |
TOM SIMPSON |
Signed |