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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Employer: Type of Entity: Address of Employer's Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Understanding Confirmation: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness 1: Full Name of Witness 2: Signing Indication: Check either alternative (1) or (2): Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Employer of Authorized Agent: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
139 2020-04-28 10:11 Anonymous (not verified) 74.84.101.138 Nisse Preschool & Kids Place Partnership 311 College Drive Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-26 Kathleen Schutte chelsea.whalen@upperiowains.com Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed (1) The employer does not elect the employers’ liability coverage. Kathleen Schutte chelsea.whalen@upperiowains.com Treasurer Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed
140 2020-04-28 10:13 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-21 John D Noel chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed (1) The employer does not elect the employers’ liability coverage. John D Noel chelsea.whalen@upperiowains.com President Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed
141 2020-04-28 10:14 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-02 Steven Matter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Bobbi Jo Berg Robin C Schultz Signed (1) The employer does not elect the employers’ liability coverage. Steven Matter chelsea.whalen@upperiowains.com Secretary Decorah Winneshiek IA BOBBI JO BERG Robin C Schultz Signed
142 2020-04-28 10:16 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 Timothy A Stoddard chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed (1) The employer does not elect the employers’ liability coverage. Timothy A Stoddard chelsea.whalen@upperiowains.com Treasurer Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed
867 2022-01-28 12:19 Anonymous (not verified) 207.199.212.86 Gary Elsbernd DBA RGM Dairy Farm Proprietorship 1538 230th St Calmar IA, 52132 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. 2022-01-21 Gary Elsbernd lacy@cioia.com Calmar Winneshiek Iowa Joel Rochford Lacy Carolan Signed (1) The employer does not elect the employers’ liability coverage. Gary Elsbernd lacy@cioia.com Self Calmar Winneshiek Iowa Joel Rochford Lacy Carolan Signed
868 2022-01-28 12:22 Anonymous (not verified) 207.199.212.86 Gary Elsbernd DBA RGM Dairy Farm Proprietorship 1538 230th St Calmar IA, 52132 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. 2022-01-21 Marie Elsbernd lacy@cioia.com Calmar Winneshiek Iowa Joel Rochford Lacy Carolan Signed (1) The employer does not elect the employers’ liability coverage. Marie Elsbernd lacy@cioia.com Spouse Calmar Winneshiek Iowa Joel Rochford Lacy Carolan Signed
1596 2023-04-24 15:48 Anonymous (not verified) 94.188.205.174 Loyal Transport INC Proprietorship 1987 Middle Calmar Road, Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-01 Lloyd Bjergum aryan1950@hotmail.com Decorah, IA Winneshiek Iowa Allen Monroe Amy Ryan Signed (1) The employer does not elect the employers’ liability coverage. Lloyd Bjergum aryan1950@hotmail.com Self Decorah, Winneshiek Iowa Allen Monroe Amy Ryan Signed
1677 2023-06-02 11:37 Anonymous (not verified) 94.188.207.230 Karl Klotzbach Proprietorship 403 Jefferson, Decorah IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-02 Karl Klotzbach kdklotzbach@gmail.com Decorah Winneshiek Iowa Robin Schultz Jane Regan Signed (1) The employer does not elect the employers’ liability coverage. Karl Klotzbach kdklotzbach@gmail.com Employer Decorah Winneshiek Iowa Robin Schutlz Jane M Regan Signed
1780 2023-08-03 16:50 Anonymous (not verified) 94.188.207.230 S-N-T BRINKMAN TRANSFER LLC Proprietorship 401 East Dewey Street Cassville, WI 53806 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. 2023-07-01 Todd A Brinkman sntbrink@hotmail.com Cassville Wisconsin Wisconsin Todd A Brinkman Todd A Brinkman Signed (1) The employer does not elect the employers’ liability coverage. Todd A Brinkman sntbrink@hotmail.com Self employed Cassville Wisconsin Wisconsin Todd Brinkman Todd Brinkman Signed
201 2020-07-09 11:07 Anonymous (not verified) 167.142.98.40 Brock Chisum Proprietorship 369 Wise Rd., Decatur, TX76234 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Brock Chisum bchisum@hotmail.com Decatur, TX Wise Texas Lakota Larson Ryan Stott Signed (1) The employer does not elect the employers’ liability coverage. Brock Chisum bchisum@hotmail.com Self Decatur Wise Texas Lakota Larson Ryan Stott Signed
535 2021-06-04 13:16 Anonymous (not verified) 192.119.129.187 KMA Communications, LLC Limited Liability Company 435 croston rd. Stockport, OH 43787 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-04 Kenneth Stephen Alsup kenneth.alsup@yahoo.com Walker Wood West Virginia Stephen Alsup Nancy Alsup Signed (1) The employer does not elect the employers’ liability coverage. Kenneth Stephen Alsup kenneth.alsup@yahoo.com Same Person Walker Wood West Virginia Stephen Alsup Nancy Alsup Signed
73 2020-02-21 13:44 Anonymous (not verified) 192.30.185.233 Viejos Masnry construction LLC Limited Liability Company 1708 Villa Ave. Sioux City IA 51103 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-13 Oscar Castro Ramirez veijosconstruction@gmail.com Sioux City Woodbury Iowa JEFFREY H MCCLINTOCK Nancy Fleming Signed (1) The employer does not elect the employers’ liability coverage. Viejos Masonry Construction LLC veijosconstruction@gmail.com Owner/President SIOUX CITY Woodbury Iowa Nancy Fleming Jeffrey Hugh McClintock Signed
266 2020-09-21 18:08 Anonymous (not verified) 174.126.94.77 Club Fantasy Inc. Limited Liability Company P.O. Box 5115 Sioux City Iowa 51102 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. 2020-08-21 Curtis A. Behr cacbehr@aol.com Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed (1) The employer does not elect the employers’ liability coverage. Curtis A. Behr cacbehr@aol.com Self Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed
314 2020-11-13 10:18 Anonymous (not verified) 66.172.192.197 Helaine W. Sherman Trust Proprietorship P.O. Box 717, Sioux City, Iowa 51102 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. 2020-11-13 Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed (1) The employer does not elect the employers’ liability coverage. Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Trustee of Trust Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed
339 2020-12-15 15:23 Anonymous (not verified) 74.221.46.229 CORRECTIONVILLE GOLF CLUB INC Limited Liability Company 1300 HACKBERRY STREET CORRECTIONVILLE IA 51016 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. 2020-12-15 KATIE EDWARDS KEDWARDS@FNBCORRECTIONVILLE.COM CORRECTIONVILLE WOODBURY IA CANDACE JACOBSON AMBER HANSEN Signed (1) The employer does not elect the employers’ liability coverage. KIM MEBIUS KMEBIUS@FNBCORRECTIONVILLE.COM PRESIDENT CORRECTIONVILLE WOODBURY IA CANDACE JACOBSON AMBER HANSEN Signed
380 2021-02-01 15:04 Anonymous (not verified) 192.30.185.142 Chelos Framing Crew Proprietorship 501 Colon Street, Sioux City, 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. 2021-02-01 Marcelo Lopez chelosframingcrew@icloud.com Sioux City Woodbury IA Katie Jenks Virginia Anderson Signed (1) The employer does not elect the employers’ liability coverage. Marcelo Lopez chelosframingcrew@icloud.com Owner Sioux City Woodbury IA Katie Jenks Virginia Anderson Signed
382 2021-02-02 13:19 Anonymous (not verified) 192.30.185.142 Double D Weatherization Proprietorship 2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-02 Dale Gernhart lakehome@longlines.com Sergeant Bluff Woodbury IA Nate Blaeser Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Dale Gerhart lakehome@longlines.com Self Sergeant Bluff Woodbury IA Nate Blaeser Jennie Ebner Signed
392 2021-02-11 10:07 Anonymous (not verified) 192.30.185.142 Neiman Electric Proprietorship 301 West Creek Dr, Lawton, IA 51030 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-11 John Neiman, Jr neiman009@yahoo.com Lawton Woodbury IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. John Neiman, Jr. neiman009@yahoo.com Owner Lawton Woodbury IA Katie Jenks Nate Blaeser Signed
399 2021-02-15 14:44 Anonymous (not verified) 192.30.185.142 Poss Concrete Proprietorship 3106 Dodge Ave, Sioux City, IA 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-15 Corey Poss coreyposs1@gmail.com Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Corey Poss coreyposs1@gmail.com Owner Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed
400 2021-02-15 14:44 Anonymous (not verified) 192.30.185.142 Certified Radon Mitigation Proprietorship 4304 Garretson Ave, Sioux City, IA 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-15 Erik Poss rn222@outlook.com Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Erik Poss rn222@outlook.com Owner Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed
403 2021-02-16 11:20 Anonymous (not verified) 192.30.185.142 Rodrigo Ochoa Proprietorship 3310 5th St, Sioux City, IA 51105 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-16 Rodrigo Ochoa jesusochoa1976@icloud.com Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Rodrigo Ochoa jesusochoa1976@icloud.com Owner Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed
453 2021-03-26 08:27 Anonymous (not verified) 192.30.185.142 DYAD LLC Partnership 2308 Summit St, Sioux City, IA 51104 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. 2021-03-26 Andrew Glisar john@kellyconstruction.com Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Andrew Glisar john@kellyconstruction.com Owner/Partner Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed
654 2021-09-24 15:08 Anonymous (not verified) 199.247.64.87 Steve Porter DBA Precision Striping Proprietorship 408 Embassy Ct. Sergeant Bluff, IA 51054 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-23 Steve Porter steve.porter2710@gmail.com Sergeant Bluff Woodbury Iowa Josh Nichols Steve Porter Signed (1) The employer does not elect the employers’ liability coverage. Jana Reich JNeuzil@reichpainting.com Office Manager Sioux City Woodbury Iowa Josh Nichols Steve Porter Signed
774 2021-11-29 12:28 Anonymous (not verified) 174.198.82.208 Demetrio's Construction Proprietorship 2018 Heights Ave Sioux City, IA 51104 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. 2021-11-29 Guillermo Demetrio moralesdalia44@yahoo.com Sioux City Woodbury Iowa Dalia E. Morales Galvez Vanessa Topete Signed (1) The employer does not elect the employers’ liability coverage. Guillermo Demetrio moralesdalia44@yahoo.com Owner Sioux City Woodbury Iowa Dalia Morales Galvez Vanessa Topete Signed
1059 2022-04-19 15:06 Anonymous (not verified) 64.186.23.83 CORRECTIONVILL GOLF CLUB, INC Limited Liability Company 1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-19 NICK HEATH dogboy3485@yahoo.com CORRECTIONVILLE WOODBURY IOWA CANDACE JACOBSON AMBER HANSEN Signed (1) The employer does not elect the employers’ liability coverage. KATIE EDWARDS kedwards@fnbcorrectionville.com SEC/TREASURER CORRECTIONVILLE WOODBURY IOWA CANDACE JACOBSON AMBER HANSEN Signed
1060 2022-04-19 15:08 Anonymous (not verified) 64.186.23.83 CORRECTIONVILLE GOLF CLUB, INC Limited Liability Company 1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-19 ADAM KELLY dslkraz@gmail.com CORRECTIONVILLE WOOD IWOA CANDACE AMBER HANSEN Signed (1) The employer does not elect the employers’ liability coverage. KATIE EDWARDS kedwards@fnbcorrectionville.com SEC/TREASURER CORRECTIONVILLE WOODBURY IOWA CANDACE JACOBSON AMBER HANSEN Signed
1525 2023-03-20 15:28 Anonymous (not verified) 94.188.205.174 Valentin Saucedo Proprietorship 1811 W 5th St, Sioux City, IA 51103 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. 2023-03-20 Valentin Saucedo sauceds20@gmail.com Sioux City Woodbury IA Jacob Goodin Kevin Small Signed (1) The employer does not elect the employers’ liability coverage. Valentin Saucedo sauceds20@gmail.com Sole Prop Sioux City Woodbury IA Jacob Goodin Kevin Small Signed
1528 2023-03-22 10:37 Anonymous (not verified) 94.188.205.175 Uhl Cattle Company Partnership 3329 Ozark Ave, Mapleton IA 51034 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. 2023-03-01 Tonya Jean Uhl tonyajuhl@gmail.com Mapleton Woodbury iowa Keaten Anthony Miller Erik Michael Boyle Signed (1) The employer does not elect the employers’ liability coverage. Tonya Jean Uhl tonyajuhl@gmail.com Owner Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed
1529 2023-03-22 10:40 Anonymous (not verified) 94.188.205.175 Uhl Cattle Company Partnership 3329 Ozark Ave, Mapleton IA 51034 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. 2023-03-01 Troy Michael Uhl troyuhl1224@gmail.com Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed (1) The employer does not elect the employers’ liability coverage. Tonya Jean Uhl tonyajuhl@gmail.com Brother Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed
2046 2024-02-15 11:29 Anonymous (not verified) 94.188.205.175 Ervin Cabrera Mendez Proprietorship 4822 Meadowlark Lane, Sioux City, Iowa 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-01 Ervin Cabrera Mendez ervincabrera89@gmail.com Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Ervin Cabrera Mendez ervincabrera89@gmail.com Owner Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed
2049 2024-02-16 09:19 Anonymous (not verified) 94.188.205.169 Cadona Construction LLC Limited Liability Company 215 S Leonard, Sioux City, IA 51103 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. 2024-02-16 Luis Cardona luiscardona5151@gmail.com Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Luis Cardona luiscardona5151@gmail.com Owner Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed
1618 2023-04-28 11:10 Anonymous (not verified) 94.188.205.167 Hunter Flying Service, LLC 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. 2023-04-28 James Lynn Cary hunterflying@att.net Hunter Woodruff Arkansas Karen Gifford Jason White Signed (1) The employer does not elect the employers’ liability coverage. James Lynn Cary hunterflying@att.net Self Hunter Woodruff AR Karen Gifford Jason White Signed
1619 2023-04-28 11:20 Anonymous (not verified) 94.188.207.224 Hunter Flying Service, LLC 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. 2023-04-28 Adam Towe hunterflying@att.net Hartselle Morgan Alabama Ronnie Skinner Karen Gifford Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Lynn Cary hunterflying@att.net Owner Hunter Woodruff Arkansas Ronnie Skinner Karen Gifford Signed
290 2020-10-23 15:13 Anonymous (not verified) 74.42.24.42 Gunter Trucking LLC Limited Liability Company 704 River Ave N., Belmond, IA 50421 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. 2020-10-23 Michael James Gunter mikegunter885@yahoo.com Belmond Wright Iowa Sondra Faye Godsell Lori Lynn Studer Signed (1) The employer does not elect the employers’ liability coverage. Michael James Gunter mikegunter885@yahoo.com Owner Belmond Wright Iowa Sondra Faye Godsell Lori Lynn Studer Signed
518 2021-05-12 19:22 Anonymous (not verified) 184.105.50.148 Angela Smith and Christopher Smith Proprietorship 2321 130th Street Belmond, IA 50421 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-08 Christopher Lynn Smith 1angismith@gmail.com Belmond Wright Iowa Betty Warrington Nicholas Mehmen Signed (1) The employer does not elect the employers’ liability coverage. Angela Kay Smith 1angismith@gmail.com Wife Belmond Wright Iowa Betty Warrington Nicholas Mehmen Signed
1653 2023-05-18 09:45 Anonymous (not verified) 94.188.205.166 Darwin Gonzales Rodriguez Proprietorship 511 5th Street NE Belmond IA 50421 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-10 Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Belmond Wright Iowa Soila Perez Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Self Belmond Wright Iowa Soila Perez Keith Clabaugh Signed
1659 2023-05-23 13:39 Anonymous (not verified) 94.188.205.168 Rosendo Mora Proprietorship 222 E Webster Street, Goldfield IA 50542 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 Rosendo Mora office.seamlesspros@icloud.com Goldfield Wright Iowa Anthony Buck Troy Knutson Signed (1) The employer does not elect the employers’ liability coverage. Rosendo Mora office.seamlesspros@icloud.com Self Goldfield Wright Iowa Anthony Buck Troy Knutson Signed
2045 2024-02-15 10:26 Anonymous (not verified) 94.188.207.227 Francesco Martinez Proprietorship 403th 7th Ave NW Clarion IA 50525 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. 2024-02-15 Francesco Martinez Martinexfrancesco99@gmail.com Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed (1) The employer does not elect the employers’ liability coverage. Francesco Martinez martinezfrancesco99@gmail.com Employer Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed
2056 2024-02-24 08:17 Anonymous (not verified) 94.188.207.230 C&C Property LLC Limited Liability Partnership PO Box 418 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-24 Joshua Darwin Wessel wesselclublambs@gmail.com Kiron Crawford IA Chad D Foust Chad A Tweeten Signed (1) The employer does not elect the employers’ liability coverage. Chad Tweeten tweeten@hotmail.com Barn Manager 1099 employee Eagle grove Wright Iowa Chad Tweeten Chad Foust Signed
1330 2022-10-11 10:59 Anonymous (not verified) 24.252.38.219 XXX Limited Liability Company XXX 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. 2022-11-15 XXX XXX@gmail.com XX XXX XXX XXX XXX Signed (1) The employer does not elect the employers’ liability coverage. XXX XXX@gmail.com XXX XXX XXX XXX XXX XXX Signed
806 2021-12-20 08:56 Anonymous (not verified) 50.124.217.66 Lyndon L Giese dba G&G Farms Trucking Proprietorship 402 St Olaf Ave S Canby, MN 56220 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. 2021-12-20 Lyndon L Giese ldgiese@frontiernet.net Canby Yellow Medicine Minnesota Jeff Sinn Tiffany Gohr Signed (1) The employer does not elect the employers’ liability coverage. Lyndon L Giese ldgiese@frontiernet.net Owner Canby Yellow Medicine Minnesota Jeff Sinn Tiffany Gohr Signed
816 2021-12-30 09:56 Anonymous (not verified) 174.199.83.133 Michael Fales Proprietorship 1987 180th 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. 2021-12-30 Michael Lee Fales Chubby__69@hotmail.com Canby Yellow Medicine Minnesota Tori Fales Jean Fales Signed (1) The employer does not elect the employers’ liability coverage. Michael Lee Fales Chubby__69@hotmail.com Owner Canby Yellow Medicine Minnesota Tori Fales Jean Fales Signed
818 2022-01-02 11:34 Anonymous (not verified) 184.94.130.66 dylan nelson trucking llc Limited Liability Company 2011 465th street hanley falls mn 56245 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 dylan nelson dylancvi@gmail.com hanley falls mn yellow medicine mn derek verhelst mike fales Signed (1) The employer does not elect the employers’ liability coverage. dylan nelson dylancvi@gmail.com owner hanley falls mn yellow medicine mn derek verhelst mike fales Signed
819 2022-01-02 11:39 Anonymous (not verified) 184.94.130.66 derek verhelst trucking inc Proprietorship 1579 270th avenue canby mn 56220 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 derek verhelst derekvtinc@gmail.com canby yellow medicine mn lois verhelst dylan nelson Signed (1) The employer does not elect the employers’ liability coverage. derek verhelst derekvtinc@gmail.com owner canby yellow medicine mn lois verhelst dylan nelson Signed
1320 2022-09-22 18:01 Anonymous (not verified) 50.33.24.168 John Miller Trucking Proprietorship 2414 180th Avenue Porter MN 56280 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. 2022-09-22 John Patrick Miller jkmiller@frontiernet.net Porter Yellow Medicine Minnesota Lois Verhelst Tricia Bueltel Signed (1) The employer does not elect the employers’ liability coverage. John Patrick Miller jkmiller@frontiernet.net Self Porter Yellow Medicine Minnesota Lois Verhelst Tricia Bueltel Signed