195 |
2020-06-29 08:55 |
Anonymous (not verified) |
107.77.173.23 |
E.S.T. Construction LLC |
Limited Liability Company |
2412 E 16th st Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-29 |
Eber Saul Torres |
estorres48@gmail.com |
Des Moines |
Polk |
Iowa |
Hailey Galdames Luna |
Abel Mejia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eber Saul Torres |
estorres48@gmail.com |
Self |
Des Moines |
Polk |
IOWA |
Hailey Galdames Luna |
Abel Mejia |
Signed |
207 |
2020-07-16 13:05 |
Anonymous (not verified) |
173.16.140.254 |
Steve Kennedy |
Proprietorship |
5108 SW 13th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Steve Kennedy |
stevekennedy@gmail.com |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Kennedy |
stevekennedy007@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
210 |
2020-07-20 13:28 |
Anonymous (not verified) |
75.162.95.97 |
RM construction |
Proprietorship |
65 SE 5TH STREET APT 4 DES MOINES IA . 50315 |
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. |
2020-07-20 |
Rafael Marquez |
marquezrafael1@outlook.com |
Des Moines |
Polk IOWA |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rafael Marquez |
marquezrafael1@outlook.com |
owner |
Des Moines |
Polk |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
212 |
2020-07-20 16:43 |
Anonymous (not verified) |
97.64.164.30 |
Bernard L. Gradoville D.D.S. |
Proprietorship |
2800 Ingersoll Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-20 |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
self |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |
220 |
2020-08-02 13:45 |
Anonymous (not verified) |
99.203.112.113 |
R&G SEAMLESS GUTTERS |
Proprietorship |
3244 Dubuque Ave, 3244 Dubuque Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-02 |
Ruben Munoz Haro |
munozharoruben@gmail.com |
Des Moines |
Polk |
Estados Unidos |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ruben Munoz- R&G SEAMLESS GUTTERS |
Munozharoruben@gmail.com |
owner |
3244 Dubuque Ave Des Moines Iowa 50317 |
polk |
iowa |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
222 |
2020-08-03 16:16 |
Anonymous (not verified) |
204.98.109.114 |
Norval Craig Michael |
Proprietorship |
640 NE 47th Place, Des Moines, IA 50313 |
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. |
2020-02-20 |
Norval Craig Michael |
accounts@dickersonmechanical.com |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nornal Craig Michael |
accounts@dickersonmechanical.com |
Self Employeed - Sole Proprietor |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
239 |
2020-08-20 14:47 |
Anonymous (not verified) |
173.23.150.218 |
Gaytan Framing LLC |
Limited Liability Company |
2418 E 37th Ct |
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. |
2020-08-20 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
Iowa |
Misael Balleza |
Carla Gaytan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Misael Balleza |
Carla Gaytan |
Signed |
247 |
2020-08-26 20:00 |
Anonymous (not verified) |
67.132.237.42 |
OPN Renovations LLC |
Limited Liability Company |
1721 63rd 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. |
2020-08-26 |
Haruko Nakata |
harunakata@hotmail.com |
Des Moines |
Iowa |
United States |
Monica Parra |
Oscar D Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Haruko Nakata |
harunakata@hotmail.com |
Single Member |
Des Moines |
Iowa |
United States |
Monica Parra |
Oscar D Perez |
Signed |
253 |
2020-09-09 12:27 |
Anonymous (not verified) |
173.18.16.129 |
H E Drywall INC |
Proprietorship |
200 E Lally 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. |
2020-09-09 |
Eriberto Castro |
hedrywall82@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
eriberto castro |
hedrywall82@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jake Hibbert |
Signed |
261 |
2020-09-17 15:52 |
Anonymous (not verified) |
65.127.131.118 |
Jesus Adrian Martinez |
Proprietorship |
1517 Searle 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. |
2020-09-17 |
Jesus Adrian Martinez |
adrianmartinezventura21@gmail.com |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesus Adrian Martinez |
adrianmarinezventura21@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Martin Pinon |
Signed |
264 |
2020-09-21 13:26 |
Anonymous (not verified) |
107.77.173.3 |
JAG Painting |
Proprietorship |
1423 Des Moines Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-21 |
Berenice S Silva |
berenicesssvaldes@gmail.com |
Des Moines |
Polk |
Iowa |
Luis Garcia |
Maria Salas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Berenice S Silva |
berenicesssvaldes@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luis Garcia |
Maria Salas |
Signed |
267 |
2020-09-22 07:04 |
Anonymous (not verified) |
74.84.65.174 |
Angel Jesus Argueta |
Proprietorship |
1523 Arlington Ave Des Moines, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-22 |
Angel Jesus Argueta |
Juanargueta22@yahoo.com |
Des Moines |
Polk |
Iowa |
Larry Eugene Guire |
Eric Michael West |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Angel Jesus Argueta |
Juanargueta22@yahoo.com |
Same |
Des Moines |
Polk |
Iowa |
Larry Eugene Guire |
Eric Michael West |
Signed |
272 |
2020-10-02 13:10 |
Anonymous (not verified) |
99.203.92.229 |
Batres Homes Renovation LLC |
Limited Liability Company |
3000 2nd Ave Des Moines 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. |
2020-10-02 |
Gabriel Antonio Batres Huezo |
gabirlebatres7@gmail.com |
Des Moines |
Polk |
Iowa |
Blanca Silvia Leiva |
Luis Mariano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Walter Alexander Batres Huezo |
wbatres12@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Blanca Silvia Leiva |
Luis Mariano |
Signed |
292 |
2020-10-27 18:15 |
Anonymous (not verified) |
173.19.162.248 |
John Lass |
Limited Liability Company |
6025 SE 16TH CT |
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. |
2020-10-27 |
John Lass |
johnwlass@gmail.com |
Des Moines |
IA |
United States |
Dawn Lass |
Gordon Lamp Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Lass |
johnwlass@gmail.com |
self |
Des Moines |
IA |
United States |
Dawn Lass |
Gordon Lamp Jr |
Signed |
294 |
2020-10-28 10:08 |
Anonymous (not verified) |
65.103.82.36 |
Des Moines Junk |
Proprietorship |
3011 Dean Ave Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Timothy Hall Sr. |
removal@dsmjunk.com |
Des Moines |
Polk |
Iowa |
eric johnson |
kayla artiolo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Hall |
removal@dsmjunk.com |
self |
des moines |
polk |
Iowa |
eric |
Kayla |
Signed |
304 |
2020-10-31 13:23 |
Anonymous (not verified) |
173.17.230.149 |
Jerome Jones |
Proprietorship |
5203 Douglas Avenue, Des Moines, IA 50310 |
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. |
2020-10-31 |
Jerome Jones |
jeromepops1@gmail.com |
Des Moines |
Polk |
IA |
Joe Simpson |
James Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerome Jones |
jeromepops1@gmail.com |
self |
Des Moines |
Polk |
IA |
Joe Simpson |
James Nelson |
Signed |
305 |
2020-11-02 08:40 |
Anonymous (not verified) |
204.124.192.31 |
JPS Framing |
Proprietorship |
102 WALL AVE - DES MOINES IA 50315 |
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. |
2020-11-02 |
JACKELYN SANCHEZ |
JPSFRAMING629@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUAN SERRANO |
JPSFRAMING629@GMAIL.COM |
EMPLOYER |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
317 |
2020-11-15 19:20 |
Anonymous (not verified) |
172.58.83.192 |
All Cut Lawn Care |
Proprietorship |
3506 Glover Ave. Des Moines Iowa 50315 |
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. |
2020-11-15 |
Michael D Money |
michaelmoney883@gmail.com |
Des Moines |
Polk |
Iowa |
Deanna L Phagan |
Diana J Jennings |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Money |
michaelmoney883@gmail.com |
Myself |
Des Moines |
Polk |
Iowa |
Deanna L Phagan |
Diana J Jennings |
Signed |
321 |
2020-11-17 10:26 |
Anonymous (not verified) |
173.18.16.129 |
Adam Quimby |
Proprietorship |
2033 10th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-01 |
Adam Quimby |
adam.m.quimby@gmail.com |
Des Moines |
Polk |
Iowa |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Quimby |
adam.m.quimby@gmail.com |
Owner |
Des Moines |
Polk |
Iow |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
328 |
2020-11-26 12:28 |
Anonymous (not verified) |
174.198.82.38 |
Duke millwright doing business as duke & sons |
Limited Liability Company |
3264 e Payton ave Des Moines iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-11-26 |
Jeremiah duke |
jpduke24.7.365@gmail.com |
Des Moines |
Polk county |
Iowa |
Daniel Patrick Hemann |
Nikki Marie Harvey |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Diana duke |
dukemillwright@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Nikki Marie Harvey |
Daniel Patrick Hemann |
Signed |
335 |
2020-12-08 11:08 |
Anonymous (not verified) |
173.18.16.129 |
quintanillas construction llc |
Limited Liability Company |
3136 6th ave des moines ia 50313 |
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. |
2020-12-08 |
maynor quintanilla |
maynorquintanilla42@gmail.com |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maynor quintanilla |
maynorquintanilla42@gmail.com |
owner |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
338 |
2020-12-13 16:31 |
Anonymous (not verified) |
107.77.161.48 |
LAVH LLC |
Limited Liability Company |
1520 E Pleasant View Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-13 |
Luis Vasquez |
vasquezluis239@gmail.com |
Des Moines |
Polk |
Iowa |
Lorena Aguilar |
Carlos Mendoza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LAVH LLC |
vasquezluis239@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Lorena Aguilar |
Carlos Mendoza |
Signed |
345 |
2020-12-29 09:20 |
Anonymous (not verified) |
173.18.16.129 |
Eben-Ezer Concrete Services |
Proprietorship |
1283 dixon st. Des Moines IA 50316 |
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. |
2020-12-29 |
Saul Artero |
Artro50313@yahoo.com |
Des Moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Saul Artero |
Artro50313@yahoo.com |
owner |
des moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
349 |
2020-12-31 17:37 |
Anonymous (not verified) |
107.77.161.33 |
JAG Painting |
Proprietorship |
1423 des moines street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-31 |
Berenice Silva |
berenicesssvaldes@gmail.com |
Des moines |
Polk |
IA |
Manuel Aguilar |
Luis Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Berenice Silva |
berenicesssvaldes@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Manuel Aguilar |
Luis Garcia |
Signed |
355 |
2021-01-11 16:29 |
Anonymous (not verified) |
173.18.16.129 |
Neil Bitting Construction |
Proprietorship |
2607 E 39th ct Des Moines 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. |
2021-01-11 |
Neil Bitting |
bittingneil@live.com |
des Moines |
polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Bitting |
bittingneil@live.com |
owner |
des moines |
polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
360 |
2021-01-12 12:08 |
Anonymous (not verified) |
75.162.189.102 |
Super Green Plus Llc |
Limited Liability Company |
3020 SE 5th 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. |
2021-01-12 |
Damon Berry |
theatvfan@gmail.com |
Des Moines |
IA |
United States |
Naki Brown |
Nakima Brown |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Super Green Plus |
theatvfan@gmail.com |
owner |
Des Moines |
IA |
United States |
Naki Brown |
Nakima Brown |
Signed |
366 |
2021-01-18 18:32 |
Anonymous (not verified) |
75.162.57.214 |
Affordable Exteriors, LLC |
Limited Liability Company |
802 east COUNTY LINE RD #57 |
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. |
2021-01-18 |
Destiny Moses |
Info@mktdsm.com |
DES MOINES |
IA |
United States |
Miguel Angel Garcia Ramirez |
Nelly Bekker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Destiny Moses |
Info@mktdsm.com |
owner |
DES MOINES |
IA |
United States |
Miguel Garcia |
Nellie Bekker |
Signed |
367 |
2021-01-21 14:18 |
Anonymous (not verified) |
107.117.168.117 |
1105 Wade St |
Proprietorship |
1105 WADE 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. |
2021-01-03 |
Jose J Castillo |
Jonathancas782@gmail.com |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose J Castillo |
Jonathancas782@gmail.com |
Owner |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
385 |
2021-02-07 12:43 |
Anonymous (not verified) |
173.17.12.148 |
H@E roofing LLC |
Limited Liability Company |
1912 Burson street Des Moines is 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-04 |
Heather Hickman |
hratherhickman@gmail.com |
Des moines |
Polk |
Iowa |
Jerry freeborn |
Ivan torres |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heather Hickman |
hratherhickman@gmail.com |
Self |
Des moines |
Polk |
Iowa |
Jerry freeborn |
Ivan torres |
Signed |
388 |
2021-02-10 11:48 |
Anonymous (not verified) |
97.125.123.32 |
Pro Bull Painting LLC |
Limited Liability Company |
1204 sampson st Des Moines IA 50316 |
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. |
2021-02-10 |
Eduardo Garcia Becerril |
probullpainting1@gmail.com |
Des Moines |
Polk |
Iowa |
Juan Carlos Garcia |
Rigoberto Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eduardo Garcia |
Probullpainting1@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan Carlos Garcia |
Rigoberto Garcia |
Signed |
395 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear 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. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
396 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear 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. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
397 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear 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. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
398 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear 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. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
404 |
2021-02-16 13:30 |
Anonymous (not verified) |
174.198.79.179 |
Topline Painting llc |
Limited Liability Company |
1603 e 32nd st Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-16 |
Michael nunez |
toplinepaintingiowa@gmail.com |
Des Moines |
Polk |
Iowa |
Jimmy nunez |
Jose Nunez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael nunez |
toplinepaintingiowa@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Jimmy nunez |
Jose nunez |
Signed |
405 |
2021-02-17 11:04 |
Anonymous (not verified) |
104.201.67.178 |
CYE Painting |
Limited Liability Company |
5202 SE 31st Ct Des Moines,IA 50320 |
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. |
2021-02-17 |
CYE Painting |
marilopez9657@yahoo.com |
Des Moines |
Polk |
Iowa |
Maricela Lopez |
Cruz Cabrera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maricela Lopez |
marilopez9657@yahoo.com |
N/a |
Des Moines |
Polk |
IA |
Maricela Lopez |
Cruz Cabrera |
Signed |
429 |
2021-03-10 12:52 |
Anonymous (not verified) |
173.23.50.65 |
Raleigh Electrical Services |
Limited Liability Company |
3747 SE 10th 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. |
2021-03-10 |
Timothy Bruce Raleigh |
tim@raleighelectrical.org |
Des Moines |
Polk |
Iowa |
Joe Coughlon |
Genna Prine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Bruce Raleigh |
tim@raleighelectrical.org |
Same |
Des Moines |
Polk |
Iowa |
Joe Coughlon |
Genna Prine |
Signed |
439 |
2021-03-18 08:09 |
Anonymous (not verified) |
172.58.86.251 |
Nancy Lopez/Lifetime Roofing and Construction Corpn |
Proprietorship |
2234 Highland St 50315 Des Moines IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-18 |
Nancy Lopez/ Lifetime Roofing and Construction Corp |
info@lifetimeroofingdsm.com |
Des Moines |
Polk |
I A |
Noe Ordaz |
Fidel Rubio |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nancy Lopez |
info@lifetimeroofingdsm.com |
Owner |
Des Moines |
Polk |
IA |
Noe Ordaz |
Fidel Rubio |
Signed |
443 |
2021-03-22 13:22 |
Anonymous (not verified) |
167.127.218.244 |
Romero Carpentry |
Proprietorship |
2060 King Ave, Apt 19, Des Moines, IA 50320 |
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. |
2021-03-22 |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Des moines |
Polk |
United States |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
445 |
2021-03-23 12:34 |
Anonymous (not verified) |
172.58.84.232 |
XD PAINTING |
Limited Liability Company |
1233 Herold Ave Des Moines Iowa 50315 |
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. |
2021-03-23 |
Daniel Alcaraz Suarez |
xdpainting@gmail.com |
Des Moines |
Polk county |
Iowa |
Anthony Maland |
Marcus Ross |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Alcaraz Suarez |
xdpainting@gmail.com |
None |
Des Moines |
Polk county |
Iowa |
Anthony maland |
Marcus Ross |
Signed |
449 |
2021-03-25 10:53 |
Anonymous (not verified) |
174.198.73.94 |
A&F Painting llc |
Limited Liability Company |
411 E Dunham ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-25 |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Des Moines |
Polk |
Iowa |
Alfonzo Afanador |
Noemi Afanador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Alfonzo Alfanador |
Noemi Alfanador |
Signed |
463 |
2021-04-06 21:34 |
Anonymous (not verified) |
173.23.145.187 |
LANTZ ELITE CARPENTRY & CONSTRUCTION INC |
Limited Liability Company |
1980 NW 94th St, Ste C Clive, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
IOWA |
PERLA LANDAVERDE |
ALMA J. GAYTAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOSE J. CASTILLO |
CASTILLOJOSEJONATHAN7@GMAIL.COM |
self |
Des Moines |
Iowa |
IOWA |
PERLA LANDAVERDE |
ALMA J. GAYTAN |
Signed |
494 |
2021-04-22 12:41 |
Anonymous (not verified) |
173.18.16.129 |
Unique Drywall Finishing LLC |
Limited Liability Company |
509 E 26th 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. |
2021-04-22 |
jose angel chavez |
uniquewal@yahoo.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Angel Chavez |
uniquewal@yahoo.com |
owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
536 |
2021-06-07 11:01 |
Anonymous (not verified) |
205.221.255.62 |
Mark Lile |
Limited Liability Partnership |
PO Box 36411 |
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. |
2021-06-07 |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Lile |
Mark@ultimateautowash.com |
Employer |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
541 |
2021-06-15 07:04 |
Anonymous (not verified) |
63.224.181.101 |
Schultes Horticulture and Landscape LLC |
Limited Liability Company |
1444 42nd 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. |
2021-06-15 |
Josh Schultes |
schulteshort@gmail.com |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Schultes |
schulteshort@gmail.com |
Self |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
547 |
2021-06-24 08:05 |
Anonymous (not verified) |
97.125.169.60 |
Tenant Improvement Services, LLC |
Limited Liability Company |
3011 Justin Drive, Urbandale, IA 50322 |
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. |
2021-06-24 |
Josh Chiles |
josh@tenantimprovementsiowa.com |
Des Moines |
Polk |
Iowa |
John Martin |
Johnny Holman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Chiles |
josh@tenantimprovementsiowa.com |
Member |
Des Moines |
Polk |
Iowa |
John Martin |
Johnny Holman |
Signed |
552 |
2021-06-29 14:55 |
Anonymous (not verified) |
97.125.35.240 |
Melo Drywall |
Proprietorship |
7500 Bloomfield Road Lot 78 Des Moines, Iowa 50320 |
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. |
2021-06-25 |
Marlene Bautista |
bbautistamarbb@gmail.com |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marlene Bautista |
bbautistamarbb@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Kelly Denger |
Signed |
554 |
2021-07-01 15:54 |
Anonymous (not verified) |
75.162.212.130 |
Avila Gutters Inc |
Proprietorship |
5901 sw 5th st Des Moines IA 50315 |
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. |
2021-06-24 |
Enrique Avila |
enrique86avila@gmail.com |
Des moines |
polk |
iowa |
Yolanda Mendoza |
Lilliana Sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enrique Avila |
enrique86Avila@gmail.com |
owner |
des moines |
polk |
iowa |
yolanda mendoza |
liliana sanchez |
Signed |
563 |
2021-07-08 12:16 |
Anonymous (not verified) |
173.17.250.209 |
Forest Avenue Outreach |
Limited Liability Company |
1600 6th Ave DSM IA 50314 |
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. |
2021-07-08 |
Maya Bromolson |
maya@goodvibesmovement.org |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maya Bromolson |
maya@goodvibesmovement.org |
Executive Director |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
565 |
2021-07-08 13:42 |
Anonymous (not verified) |
173.25.132.255 |
Communications Construction Services LLC |
Limited Liability Company |
1315 East 38th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-08 |
John McCann Jr |
communicationconstructionllc@gmail.com |
Des Moines |
IA |
United States |
Laura McCann |
David Garza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura McCann |
communicationconstructionllc@gmail.com |
spouse |
Des Moines |
IA |
United States |
John J McCann Jr |
David Christopher Garza III |
Signed |