812 |
2021-12-22 17:31 |
Anonymous (not verified) |
166.181.85.89 |
Demmer Construction |
Proprietorship |
203 Michigan Ave Farley, IA 52046 |
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. |
2021-12-22 |
Charles Demmer |
charliedemmer@gmail.com |
Farley |
Dubuque |
Ia |
Michele Demmer |
Jennifer White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Demmer |
charliedemmer@gmail.com |
Self |
Farley |
Dubuque |
Ia |
Michele Kay Demmer |
Jennifer Marie White |
Signed |
839 |
2022-01-14 10:56 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Tyler Billmeyer |
tbillmeyer@midwestsolarservices.com |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
840 |
2022-01-14 10:58 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
884 |
2022-02-02 14:10 |
Anonymous (not verified) |
104.201.67.178 |
Magdalena Lopez Raymundp |
Proprietorship |
2820Pennsylvania Ave, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Magdalena Lopez Raymundo |
scottthomascpa@msn.com |
Dubuque |
Dubuque |
Iowa |
Rich Darr |
Mari Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott D Thomas |
scottthomascpa@msn.com |
Consultant |
West Des Moines |
IA |
United States |
Rich Darr |
Mari Lopez |
Signed |
956 |
2022-03-08 13:56 |
Anonymous (not verified) |
72.13.16.196 |
Naprstek Media LLC |
Limited Liability Company |
6505 Wellington Ln, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-08 |
James Naprstek |
jimmy@kodiakcreative.com |
Dubuque |
Dubuque |
Iowa |
Trent Hanselmann |
Jonathan O'Brien |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cheyenne Moseley |
services@e.legazoom.com |
Authorized Agent |
Glendale |
Los Angeles |
CA |
Trent Hanselmann |
Jonathan O'Brien |
Signed |
1198 |
2022-07-11 15:46 |
Anonymous (not verified) |
74.84.91.178 |
Dave's Remodeling LLC |
Limited Liability Company |
2308 Long Grove Ct, Dubuque, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-01 |
Kim Kern |
davesremodeling@aol.com |
Asbury |
Dubuque |
Iowa |
Brenda Lewis |
Gabe Drewlow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kim Kern |
davesremodeling@aol.com |
co-owner |
Asbury |
Dubuque |
Iowa |
Brenda Lewis |
Gabe Drewlow |
Signed |
1239 |
2022-08-02 10:53 |
Anonymous (not verified) |
184.80.177.137 |
Jamie Ingle, DBA Jamie's Little Sunflowers |
Proprietorship |
7155 Columbus St - New Vienna, IA 52065 |
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. |
2022-08-02 |
Jamie Ingle |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
1277 |
2022-08-22 08:57 |
Anonymous (not verified) |
68.169.247.177 |
Andrew Betts |
Proprietorship |
305 3rd ave sw cascade ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Andrew Betts |
dbidrywallco@gmail.com |
Cascade |
Dubuque |
Iowa |
Jamie manternach |
Andy hall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Betts |
dbidrywallco@gmail.com |
Owner |
Cascade |
Iowa |
United States |
Jamie manternach |
Andy hall |
Signed |
1462 |
2023-02-17 13:45 |
Anonymous (not verified) |
94.188.207.227 |
Med Spa Institute of America, Dubuque LLC |
Limited Liability Partnership |
3337 Hillcrest Rd - Dubuque, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-11 |
Kaylee Webb |
jheims@english-insurance.com |
Dubuque |
Dubuque |
United States |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self |
Dyersville |
IA |
United States |
Joyce Heims |
Derrick Parsons |
Signed |
1611 |
2023-04-27 09:21 |
Anonymous (not verified) |
94.188.205.168 |
powell express moving |
Proprietorship |
2600 Marquette Pl Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
Roger Powell |
powellexpressmoving@gmail.com |
Dubuque |
Dubuque |
Iowa |
Connie Powell |
Jay Weiser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger Powell |
powellexpressmoving@gmail.com |
Self |
Dubuque |
Dubuque |
Iowa |
Connie Powell |
Jay Weiser |
Signed |
1627 |
2023-05-08 13:43 |
Anonymous (not verified) |
94.188.205.169 |
CR TOTAL PLUMBING, INC. |
Limited Liability Company |
8190 Southern Hills Circle, Dubuque, IA 52003 |
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 |
Cory Ranson |
crpipes2@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Michelle Woodman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CR Total Plumbing, Inc |
crpipes2@yahoo.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Michelle Woodman |
Signed |
1703 |
2023-06-23 08:58 |
Anonymous (not verified) |
94.188.205.175 |
Then & Kramer Construction, Inc |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
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. |
2023-06-22 |
Shannon Kramer |
dparsons@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
1704 |
2023-06-23 09:00 |
Anonymous (not verified) |
94.188.205.166 |
THen & Kramer Construcion, Inc. |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
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. |
2023-06-22 |
Dakota Kramer |
dparsons@english-insurance.com |
Epworth, |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
1713 |
2023-06-27 09:06 |
Anonymous (not verified) |
94.188.205.175 |
Ray's Painters, LLC |
Limited Liability Company |
4120 Mount Alpine Street, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-15 |
Danny Sexton |
dsexton766@gmail.com |
Dubuque |
Dubuque |
Iowa |
Donna Gotto |
Brenda Lewis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ray's Painters LLC |
dsexton766@gmail.com |
insured |
Dubuque |
Dubuque |
Iowa |
Donna Gotto |
Brenda Lewis |
Signed |
1718 |
2023-06-29 12:36 |
Anonymous (not verified) |
94.188.205.166 |
Aidan Obermueller |
Proprietorship |
2520 N Grandview Avenue, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-27 |
Aidan Obermueller |
aidanobermueller@icloud.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aidan Obermueller |
aidanobermueller@icloud.com |
self |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miler |
Signed |
1757 |
2023-07-20 14:45 |
Anonymous (not verified) |
94.188.207.230 |
Lee Steffen |
Proprietorship |
608 3rd Street NE, Farley, IA 52046 |
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. |
2023-07-20 |
Lee Steffen |
lee.steffen22@icloud.com |
Farley |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lee Steffen |
lee.steffen22@icloud.com |
Self |
Farley |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
1763 |
2023-07-26 12:46 |
Anonymous (not verified) |
94.188.207.224 |
Down Home Decor Inc |
Proprietorship |
1021 2nd Ave SE Ste 200 - Dyersville, IA 52040 |
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 |
Steve Knipper |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self agent |
Dyersville |
IA |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
1770 |
2023-07-31 14:21 |
Anonymous (not verified) |
94.188.205.168 |
D & G Communications |
Proprietorship |
405 1st St N., PO Box 11 Farley, Iowa 52046 |
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. |
2023-07-31 |
Dave Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Zack Hirsch |
Nick Hirsch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
self |
Farley |
Dubuque |
Iowa |
Zach Hirsch |
Nick Hirsch |
Signed |
1898 |
2023-11-09 09:56 |
Anonymous (not verified) |
94.188.207.227 |
RC Restoration LLC |
Limited Liability Company |
991 June Drive, Dubuque, IA 52003 |
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. |
2023-11-09 |
Luke Hoffmann |
luke@rentcube.com |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Hoffman |
luke@rentcube.com |
Owner |
Dubuque |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
1906 |
2023-11-14 13:47 |
Anonymous (not verified) |
94.188.207.223 |
HRBC Plus |
Limited Liability Company |
249 SOLOMIA CT, Peosta, IA 52068 |
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. |
2023-11-11 |
Lori S Stewart |
lori@hrbcplus.com |
PEOSTA |
Dubuque |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Stewart |
lori@hrbcplus.com |
Self |
Peosta |
Dubuque |
United States |
Mark R Stewart |
Danielle M Peterson |
Signed |
2051 |
2024-02-16 17:40 |
Anonymous (not verified) |
94.188.205.174 |
Ryans Outdoor Services LLC |
Limited Liability Company |
2731 Pinard 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. |
2024-02-16 |
Ryan Carroll |
ryancarrolls1226@icloud.com |
Dubuque |
Dubuque |
Iowa |
Rob McDonald |
Philip Grommet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Carroll |
ryancarrolls1226@icloud.com |
Self |
Dubuque |
Dubuque |
Iowa |
Rob McDonald |
Philip Grommet |
Signed |
553 |
2021-07-01 08:17 |
Anonymous (not verified) |
66.188.136.150 |
Cody Belleville |
Proprietorship |
57167 Copperdate Dr. Elkhart, IN 46516 |
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. |
2021-06-30 |
Cody Belleville |
kschumacher@tricorinsurance.com |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Belleville |
kschumacher@tricorinsurance.com |
Same |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
394 |
2021-02-11 13:32 |
Anonymous (not verified) |
216.51.194.37 |
Estherville Aviation, Inc. |
Limited Liability Company |
1672 425th Ave., Estherville, IA 51334 |
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 |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Estherville |
Emmet |
Iowa |
Elizabeth Burton |
Steve Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Owner/president |
Estherville |
Emmet |
Iowa |
Steve Erickson |
Treven Carlson |
Signed |
1026 |
2022-04-01 14:53 |
Anonymous (not verified) |
173.31.148.43 |
ARMANDO RESENDEZ |
Proprietorship |
202 S 13TH ST APT #8 ESTHERVILLE, IA 51334 |
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. |
2022-04-01 |
ARMANDO RESENDEZ |
joel@walkerinsuranceia.com |
Estherville |
EMMET |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ARMANDO RESENDEZ |
joel@walkerinsuranceia.com |
SELF |
Estherville |
EMMET |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1439 |
2023-02-06 11:00 |
Anonymous (not verified) |
96.31.1.206 |
L&C LLC |
Limited Liability Company |
615 W 6TH ST ESTHERVILLE, IA 51334 |
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. |
2023-02-06 |
CARLOS MEDINA |
joel@walkerinsuranceia.com |
Estherville |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CARLOS MEDINA |
joel@walkerinsuranceia.com |
SELF |
Estherville |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1863 |
2023-10-06 12:24 |
Anonymous (not verified) |
94.188.207.223 |
ADRIAN CAZARES HERNANDEZ |
Proprietorship |
409 N 16TH PL, ESTHERVILLE, IA 51334 |
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. |
2023-10-06 |
ADRIAN CAZARES HERNANDEZ |
JOEL@WALKERINSURANCE.COM |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ADRIAN CAZARES HERNANDEZ |
JOEL@WALKERINSURANCEIA.COM |
SELF |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2073 |
2024-03-04 15:51 |
Anonymous (not verified) |
94.188.207.227 |
JACOB HANSON |
Proprietorship |
415 N 18TH ST ESTHERVILLE, IA 51334 |
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. |
2024-03-04 |
JACOB HANSON |
HANSONONEBOY@GMAIL.COM |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JACOB HANSON |
HANSONONEBOY@GMAIL.COM |
SELF |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
558 |
2021-07-07 13:35 |
Anonymous (not verified) |
66.188.136.150 |
Austin Kalfus Sr. |
Proprietorship |
1203 Poppy Ave. Pensacola, FL 32507 |
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. |
2021-07-07 |
Austin Kalfus Sr. |
kschumacher@tricorinsurance.com |
Pensacola |
Escambia |
FL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Kalfus Sr. |
kschumacher@tricorinsurance.com |
Same |
Pensacola |
Escambia |
FL |
Mitch Kemp |
Shuree Behr |
Signed |
279 |
2020-10-19 08:02 |
Anonymous (not verified) |
66.188.136.150 |
Keith McNair |
Proprietorship |
13436 Silver Brook Dr. Pickerington, OH 43147 |
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. |
2020-10-16 |
Keith McNair |
kschumacher@tricorinsurance.com |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith McNair |
kschumacher@tricorinsurance.com |
Same |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
356 |
2021-01-11 19:39 |
Anonymous (not verified) |
66.188.136.150 |
David Whitfield |
Proprietorship |
3947 Cracker Cove 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. |
2021-01-11 |
David Whitfield |
kschumacher@tricorinsurance.com |
Canal Winchester |
Fairfield |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Whitfield |
kschumacher@tricorinsurance.com |
Same |
Canal Winchester |
Fairfield |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
275 |
2020-10-08 11:56 |
Anonymous (not verified) |
166.224.213.71 |
Michael corcoran |
Proprietorship |
311 e elm st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-07 |
Michael corcoran |
mikecorcoran1990@gmail.com |
West Union |
Fayette |
IA |
Heather corcoran |
Chris Fels |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael corcoran |
mikecorcoran1990@gmail.com |
Self |
West Union |
Fayette |
IA |
Heather corcoran |
Chris fels |
Signed |
739 |
2021-11-11 14:46 |
Anonymous (not verified) |
72.13.16.172 |
WILLIAM THIAS |
Proprietorship |
PO BOX 152 |
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 |
WILLIAM THIAS |
dave@allseasonstrucking.com |
CLERMONT |
FAYETTE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
WILLIAM THIAS |
dave@allseasonstrucking.com |
PRESIDENT |
CLERMONT |
FAYETTE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
1345 |
2022-10-25 15:25 |
Anonymous (not verified) |
166.181.82.169 |
Estling Junk and Garbage Removal |
Limited Liability Company |
660 West Main Street Apt.5 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-10-25 |
Jacob Steven Estling |
JacobEstling1@gmail.com |
Maynard |
Fayette |
Iowa |
Jacob Estling |
Jacob Estling |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jacob Steven Estling |
jacobestling1@gmail.com |
Owner |
Maynard |
Fayette |
Iowa |
Jacob Estling |
Jacob Estling |
Signed |
1654 |
2023-05-19 11:09 |
Anonymous (not verified) |
94.188.205.176 |
ST SULLIVAN CONSTRUCTION COMPANY |
Proprietorship |
1614 100TH ST., OELWEIN, IOWA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-19 |
STEVE SULLIVAN |
sullycon@msn.com |
Oelwein |
Fayette |
Iowa |
Bobbie J Bergan |
Shelby Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
STEVE SULLIVAN |
sullycon@msn.com |
OWNER |
OELWEIN |
FAYETTE |
IOWA |
BOBBIE J BERGAN |
SHELBY WILLIAMS |
Signed |
1804 |
2023-08-16 18:22 |
Anonymous (not verified) |
94.188.207.226 |
Zach Moyle Masonry |
Limited Liability Company |
7222 Great River Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-16 |
Zach Moyle |
zmoylemasonry@gmail.com |
Clermont |
FAYETTE |
FAYETTE |
Brittney Loyd |
Dave Moyle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zach Moyle |
zmoylemasonry@gmail.com |
Self |
Clermont |
FAYETTE |
FAYETTE |
Brittney Loyd |
Dave Moyle |
Signed |
1841 |
2023-09-14 13:52 |
Anonymous (not verified) |
94.188.207.225 |
Double M Construction LLC |
Limited Liability Company |
3886 Diamond Rd, Elgin, IA 52141 |
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. |
2023-05-16 |
Eli Miller |
elimiller@gmail.com |
Iowa |
Fayette |
Iowa |
Julie Schick |
Kelly Matt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eli Miller |
elimiller@gmail.com |
self |
Elgin |
Fayette |
Iowa |
Julie Schick |
Kelly Matt |
Signed |
1843 |
2023-09-14 14:12 |
Anonymous (not verified) |
94.188.205.167 |
Rosenbum Construction, LLC |
Limited Liability Company |
720 South Street, Arlington, Iowa 50606 |
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. |
2022-09-02 |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Self |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
1966 |
2023-12-27 13:17 |
Anonymous (not verified) |
94.188.205.177 |
Jake Borntreger |
Proprietorship |
50 Stone St Clermont, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-25 |
Jake Borntreger |
darrele@ciains.biz |
Clermont |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jake Borntreger |
darrele@ciains.biz |
self |
Clermont |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1967 |
2023-12-27 13:28 |
Anonymous (not verified) |
94.188.207.225 |
Marvin Gingrich |
Proprietorship |
114641 Chariot Rd Elgin Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-25 |
Marvin Gingerich |
darrele@ciains.biz |
Elgin |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Gingerich |
darrele@ciaisn.biz |
Self |
Elgin |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
319 |
2020-11-16 19:24 |
Anonymous (not verified) |
173.30.37.132 |
Nathan Wright |
Proprietorship |
500 2nd Avenue, Charles City, Iowa 50616 |
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. |
2020-11-16 |
Nathan Robert Wright |
nrwright85@yahoo.com |
Charles City |
Floyd |
Iowa |
Jeff Wright |
Marsha Wright |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Robert Wright |
nrwright85@yahoo.com |
Self |
Charles City |
IA |
IA |
Jeff Wright |
Marsha Wright |
Signed |
493 |
2021-04-22 08:54 |
Anonymous (not verified) |
66.188.136.150 |
Frank Lantz |
Proprietorship |
609 Clinton Street, Charles City, IA 50616 |
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 |
Frank Lentz |
kschumacher@tricorinsurance.com |
Charles City |
Floyd |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frank Lantz |
kschumacher@tricorinsurance.com |
Same |
Charles City |
Floyd |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
810 |
2021-12-22 15:13 |
Anonymous (not verified) |
167.142.30.134 |
Bouillon Lawn Care |
Proprietorship |
3074 Lodge Ave Greene, IA 50636 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-22 |
Jerry Bouillon |
greeneflowerman@yahoo.com |
Greene |
Floyd |
Iowa |
Lucas Wedeking |
Misty Osborn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Bouillon |
Greeneflowerman@yahoo.com |
Self |
Greene |
Floyd |
Iowa |
Lucas Wedeking |
Misty Osborn |
Signed |
857 |
2022-01-26 16:27 |
Anonymous (not verified) |
207.199.212.86 |
Grahm's Tree Service |
Proprietorship |
406 2nd Ave Charles City, IA 50616 |
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. |
2021-07-22 |
Graham Kuethe |
lacy@cioia.com |
Charles City |
Floyd |
Iowa |
Lacy Carolan |
Tony Trower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Graham Kuethe |
lacy@cioia.com |
Owner |
Charles City |
Floyd |
Iowa |
Lacy Carolan |
Tony Trower |
Signed |
1652 |
2023-05-17 20:44 |
Anonymous (not verified) |
94.188.205.167 |
Fox Trucking |
Proprietorship |
2774 March Ave Greene Ia. 50636 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-17 |
Chet D. Fox |
cjakfox@yahoo.com |
Greene |
Floyd |
Iowa |
Jack Dwyer |
Chad Olson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chet Fox |
cjakfox@yahoo.com |
myself |
Greene |
Floyd |
Iowa |
Jack Dwyer |
Chad Olson |
Signed |
208 |
2020-07-16 20:24 |
Anonymous (not verified) |
216.127.193.93 |
Sequoia Integrative Medical Services |
Limited Liability Company |
W2560 Birschbach Drive, Mount Calvary, WI, 53057 |
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. |
2020-07-16 |
Chad Weston Gardner |
chadwestongardner@yahoo.com |
Mount Calvary |
Fond du Lac |
Wisconsin |
Emily Lucht |
Ron Carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Weston Gardner |
chadwestongardner@yahoo.com |
Self |
Mount Calvary |
Fond du Lac |
Wisconsin |
Emily Lucht |
Ron Carpenter |
Signed |
213 |
2020-07-21 17:47 |
Anonymous (not verified) |
107.77.206.41 |
Sequoia integrative medical services |
Limited Liability Company |
W2560 birschbach drive, mount Calvary, WI 53057 |
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. |
2020-07-16 |
Mary Kate friess |
mkfriess71@gmail.com |
Fond du lac |
Fond du lac |
WI |
Gordon Lewis |
Ron carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mary Kate friess |
mkfriess71@gmail.com |
Self |
Fond du lac |
Fond du lac |
Wi |
Gordon Lewis |
Ron carpenter |
Signed |
926 |
2022-02-17 15:20 |
Anonymous (not verified) |
166.181.83.68 |
Staley Trucking LLC |
Limited Liability Company |
1388 140th 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. |
2022-02-17 |
Travis Staley |
staleyracing121@gmail.com |
Hampton |
Franklin |
IA |
Tyler Staley |
Jeff Staley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Staley |
staleyracing121@gmail.com |
President |
Hampton |
Franklin |
IA |
Tyler Staley |
Jeff Staley |
Signed |
939 |
2022-02-28 13:46 |
Anonymous (not verified) |
173.23.228.17 |
H & T Ziesman, LLC |
Limited Liability Company |
575 Nuthatch Iowa Falls IA 50126 |
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. |
2022-02-28 |
Heath Ziesman |
heathziesman87@gmail.com |
Iowa Falls |
Franklin |
Iowa |
Jeanne Rieks |
Kelly Reed |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath ZIesman |
heathziesman87@gmail.com |
Owner |
Iowa Falls |
Franklin |
Iowa |
Jeanne Rieks |
Kelly Reed |
Signed |
997 |
2022-03-23 06:15 |
Anonymous (not verified) |
167.142.233.235 |
Betsy Harms Agency LLC |
Limited Liability Company |
101 Sherman Ave, Ackley, IA 50601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Betsy Harms |
bharms@phillipsstafford.com |
Ackley |
Franklin |
IA |
Levi Harms |
Patricia Harms |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Betsy Harms |
bharms@phillipsstafford.com |
Self |
Ackley |
Franklin |
IA |
Levi Harms |
Patricia Harms |
Signed |
2158 |
2024-04-17 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Mildred Lopez |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
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. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Mark Morrison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Mark Morrison |
Signed |