569 |
2021-07-09 12:18 |
Anonymous (not verified) |
173.17.250.209 |
Forest Ave Outreach dba Good Vibes Movement |
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. |
2021-07-09 |
Ben Spellman |
ben@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 |
581 |
2021-07-22 14:29 |
Anonymous (not verified) |
205.221.255.62 |
MartinHumphrey |
Limited Liability Company |
Cummins Rd. Apt 202 |
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 |
Martin Luverne Humphrey Jr. |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Ioea |
George Porter |
Gerald Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
George Porter |
Gerald Lund |
Signed |
584 |
2021-07-23 15:38 |
Anonymous (not verified) |
75.162.41.54 |
Bradens Roofing & Construction LLc |
Limited Liability Company |
2450 Hart Ave, 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. |
2021-07-23 |
Arsenio Vargas |
avargas409@gmail.com |
Des Moines |
Polk |
Iowa |
Marc Black |
Jason Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arsenio Vargas |
avargas409@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Marc Black |
Jason Anderson |
Signed |
588 |
2021-07-27 19:59 |
Anonymous (not verified) |
75.162.226.22 |
Andres Martinez |
Limited Liability Company |
3903 SW 3rd St. 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. |
2021-07-27 |
Andres Martinez |
and.am12am@gmail.com |
Des Moines |
Polk |
Iowa |
Carla Martinez |
Librado Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andres Martinez |
and.am12am@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Carla Martinez |
Librado Martinez |
Signed |
589 |
2021-07-28 16:09 |
Anonymous (not verified) |
97.125.35.240 |
Sotero Alonso Calderon Velasquez |
Proprietorship |
1312 Idaho 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. |
2021-07-26 |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
subcontractor |
Des MOines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
615 |
2021-08-20 16:22 |
Anonymous (not verified) |
50.81.152.147 |
CPIA Home Specialists LLC |
Limited Liability Company |
1214 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. |
2021-08-20 |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
620 |
2021-08-26 16:26 |
Anonymous (not verified) |
75.162.146.246 |
Daniel Meza Reyes |
Proprietorship |
1640 E Army Post RD 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. |
2021-08-23 |
Daniel Meza Reyes |
danielmr9247@gmail.com |
Des Moines |
polk |
IA |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Meza Reyes |
danielmr9247@gmail.com |
self |
Des Moines |
polk |
IA |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
625 |
2021-08-30 20:39 |
Anonymous (not verified) |
173.16.140.101 |
Phthalo Consulting LLC |
Limited Liability Company |
2917 47th St, 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. |
2021-08-30 |
Angela Stone-Wiegert |
angela@phthaloconsulting.com |
Des Moines |
Polk |
Iowa |
Sonya Shippy |
Kenny Shippy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Angela Stone-Wiegert |
angela@phthaloconsulting.com |
Owner |
Des Moines |
Polk |
Iowa |
Sonya Shippy |
Kenny Shippy |
Signed |
627 |
2021-08-31 16:12 |
Anonymous (not verified) |
173.18.16.129 |
D's Home Improvement |
Limited Liability Company |
665 27th St Des Moines IA 50312 |
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. |
2021-08-31 |
Dustin Mitchell |
dustinmitchell8855@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Mitchell |
dustinmitchell8855@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
631 |
2021-09-02 22:46 |
Anonymous (not verified) |
173.23.144.4 |
Lopez Framing LLC |
Limited Liability Company |
566 walker 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. |
2021-09-02 |
Diana A Garcia Lopez |
lopezframing0702@gmail.com |
Des moines |
Polk |
Iowa |
Marlon Lopez |
Jennifer Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Diana A Garcia Lopez |
lopezframing0702@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Marlon Lopez |
Jennifer Reyes |
Signed |
634 |
2021-09-10 13:41 |
Anonymous (not verified) |
173.23.145.231 |
julio medina |
Proprietorship |
609 boyd st. des moines, iowa 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. |
2021-09-10 |
julio medina |
medinajulio10001@gmail.com |
des moines |
polk |
iowa |
jose rivas |
Virginia Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julio Medina |
medinajulio10001@gmail.com |
owner |
des moines |
polk |
iowa |
jose Rivas |
Virginia Gomez |
Signed |
639 |
2021-09-13 16:10 |
Anonymous (not verified) |
50.81.97.207 |
Copic Home Maintenance LLC dba Des Moines Drywall Repair |
Limited Liability Company |
1548 24th 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. |
2021-09-13 |
Clint R Copic |
crcopic@gmail.com |
Des Moines |
Polk |
Iowa |
Veronica G. Torres |
Dan Waidelich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clint R Copic |
dmdrywallrepair@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Veronica G Torres |
Dan Waidelich |
Signed |
641 |
2021-09-17 09:16 |
Anonymous (not verified) |
72.255.121.118 |
Osman Gonzalez-Sarceno |
Proprietorship |
1403 Aspen Dr Adel, 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. |
2021-09-17 |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
IA |
Melissa Bolanos |
Brianna Fuller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Owner |
Des Moines |
Polk |
Iowa |
Melissa Bolanos |
Brianna Fuller |
Signed |
648 |
2021-09-21 10:03 |
Anonymous (not verified) |
97.125.32.164 |
Manuel Morales |
Proprietorship |
1302 13th St Des Moines, Iowa 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. |
2021-09-15 |
Manuel Morales |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Morales |
deb@picowa.com |
subcontractor |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
668 |
2021-10-12 16:11 |
Anonymous (not verified) |
173.18.22.217 |
Mo's Cleaning LLC |
Limited Liability Company |
1412 E 23rd 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. |
2021-10-12 |
Melissa Jones |
commcleanwithme123@gmail.com |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Jones |
commcleanwithme123@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
672 |
2021-10-13 16:05 |
Anonymous (not verified) |
75.162.218.218 |
Arturos Interiors LLC |
Limited Liability Company |
3305 se 22nd apt 15 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. |
2021-09-29 |
Arturo mejia |
arturomcruz20@hotmail.com |
Des Moines |
polk |
IA |
yolanda mendoza |
liliana sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arturo Mejia |
arturomcruz20@hotmail.com |
member |
Des Moines |
polk |
IA |
Yolanda Mendoza |
lialiana sanchez |
Signed |
675 |
2021-10-15 11:22 |
Anonymous (not verified) |
75.162.156.37 |
MCG FLOORING, LLC |
Limited Liability Company |
2115 CARPENTER AVE DES MOINES IA 50311 |
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. |
2021-10-15 |
GABRIELA GOMEZ |
MCGFLOORINGLLC@GMAIL.COM |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MCG FLOORING, LLC |
MCGFLOORINGLLC@GMAIL.CON |
OWNER |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
676 |
2021-10-15 11:29 |
Anonymous (not verified) |
75.162.156.37 |
MCG FLOORING, LLC |
Limited Liability Company |
2115 CARPENTER AVE DES MOINES, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-10-15 |
MANUEL CONTRERAS BERNAL |
MCGFLOORINGLLC@GMAIL.COM |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
MCG FLOORING, LLC |
MCGFLOORINGLLC@GMAIL.CON |
OWNER |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
679 |
2021-10-18 13:14 |
Anonymous (not verified) |
173.18.22.217 |
Xscape Extreme Hard & Landscape |
Proprietorship |
3215 E 25th CT Bldg 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. |
2021-10-18 |
Mike Tapper |
Tapper4981@gmail.com |
Des Moines |
Polk |
IA |
Lesa Dillon |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Tapp |
Tapper4981@gmail.com |
Owner |
Des Moines |
Des Moines |
IA |
Lesa Dillon |
Kelly Coluzzi |
Signed |
681 |
2021-10-19 15:44 |
Anonymous (not verified) |
65.144.174.26 |
Humberto Albino |
Proprietorship |
3914 Aurora Ave 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. |
2021-10-19 |
Humberto Albino |
albinohumberto73@gmail.com |
Des Moines |
Polk |
Iowa |
Miguel Albino |
Jesus Albino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Humberto Albino |
albinohumberto73@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Miguel Albino |
Jesus Albino |
Signed |
684 |
2021-10-20 13:25 |
Anonymous (not verified) |
65.144.174.26 |
A and H Home Improvement |
Limited Liability Company |
600 NE 64th 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. |
2021-10-20 |
Ivan A. Abel |
aandhhomeimprovement@gmail.com |
Des Moines |
Polk |
Iowa |
Ken Krogman |
Bruce Baumgarn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ivan A. Abel |
aandhhomeimprovement@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Ken Krogman |
Bruce Baumgarn |
Signed |
685 |
2021-10-20 14:14 |
Anonymous (not verified) |
65.144.174.26 |
william c sawhill |
Proprietorship |
1625 Delaware Ave, Des Moines, 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. |
2021-10-20 |
William C Sawhill |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
Iowa |
Nicholas W Sawhill |
Jenny M Steben |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William C Sawhill |
workorders@shoproyalflooring.com |
Self |
Des Moines |
Polk |
Iowa |
Nicholas W Sawhill |
Jenny M Steben |
Signed |
686 |
2021-10-20 18:43 |
Anonymous (not verified) |
173.27.196.168 |
Royal Flooring |
Proprietorship |
11801 Hickman Rd Urbandale, IA 50323 United States |
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. |
2021-10-20 |
Joel Cisneros |
auroraramos476@gmail.com |
Des Moines |
Polk county |
Iowa |
Aurora Cisneros |
Maria Arroyo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Royal Flooring |
cisnerostile476@gmail.com |
Employee |
Clive |
Dallas |
Iowa |
Aurora Cisneros |
Maria Arroyo |
Signed |
690 |
2021-10-26 14:23 |
Anonymous (not verified) |
65.144.174.26 |
Santiago Rojas |
Proprietorship |
1359 22nd st Des Moines, IA 50311 |
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. |
2021-10-26 |
Santiago Rojas |
rojassr09@gmail.com |
Des Moines |
Polk |
Iowa |
David Rojas |
Beatriz Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Santiago Rojas |
rojassr09@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
David Rojas |
Beatriz Hernandez |
Signed |
691 |
2021-10-26 14:54 |
Anonymous (not verified) |
65.144.174.26 |
Alfonso Montoya |
Proprietorship |
2114 Nw Maple 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. |
2021-10-26 |
Alfonso Montoya |
fonzflooring@gmail.com |
Des Moines |
Polk |
Iowa |
Hector Montoya |
Victor Montoya |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alfonso Montoya |
fonzflooring@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Hector Montoya |
Victor Montoya |
Signed |
693 |
2021-10-26 15:03 |
Anonymous (not verified) |
65.144.174.26 |
Diamante Tile |
Proprietorship |
1403 Aspen Dr Adel, IA 50003 |
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. |
2021-10-26 |
Octavio Bermudez |
aerosobo@gmail.com |
Des Moines |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Octavio Bermudez |
aerosobo@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
696 |
2021-10-28 10:33 |
Anonymous (not verified) |
173.18.85.215 |
Saunders Construction |
Proprietorship |
7304 SW 14th St 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. |
2021-10-28 |
Charles A Saunders |
charlessaunders901@gmail.com |
Des Moines |
IA |
United States |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Saunders |
charlessaunders901@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
701 |
2021-10-29 18:35 |
Anonymous (not verified) |
173.18.85.215 |
Saunders Construction |
Proprietorship |
7304 SW 14th 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. |
2021-10-29 |
Charles Saunders |
charlessaunders901@gmail.com |
Des Moines |
Iowa |
Iowa |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Saunders |
charlessaunders901@gmail.com |
Owner |
Des Moines |
IA |
United States |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
703 |
2021-11-01 11:25 |
Anonymous (not verified) |
65.144.174.26 |
G & D Tile |
Proprietorship |
2210 E Rose Ave Apt 9 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. |
2021-11-01 |
Gerson Mejia |
gersonmejia25@icloud.com |
Des Moines |
Polk |
Iowa |
Katherine Castillo |
Jose Leonardo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerson Mejia |
gersonmejia25@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Katherine Castillo |
Jose Leonardo |
Signed |
732 |
2021-11-09 15:25 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick 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. |
2021-11-09 |
Ryan Drabek |
ryand@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Dustin Kohler |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Warren |
Iowa |
Trevor Spidle |
Dustin Kohler |
Signed |
733 |
2021-11-09 15:35 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick 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. |
2021-11-09 |
Dustin Kohler |
dustink@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
torywebbdmi@gmail.com |
Owner, Management |
Norwalk |
Warren |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
747 |
2021-11-12 15:08 |
Anonymous (not verified) |
75.162.157.80 |
Unique Hardwood Floors, LLC |
Limited Liability Company |
1202 Army Post Rd. 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. |
2021-11-12 |
Jose A Dominguez Lopez |
uniquefloorsdmi@gmail.com |
Des Moines |
USA |
Iowa |
Elizabeth Dominguez |
Liliana Sanchez Gutierrez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose A Dominguez Lopez |
uniquefloorsdmi@gmail.com |
Owner |
Des Moines |
USA |
Iowa |
Elizabeth Dominguez |
Liliana Sanchez Gutierrez |
Signed |
759 |
2021-11-19 18:54 |
Anonymous (not verified) |
173.23.148.83 |
EFP Construction |
Limited Liability Company |
1825 East Grand Ave Des Moines, Iowa 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. |
2021-11-19 |
Bobby Perry |
efpconstruction21@gmail.com |
Des Moines |
Polk |
Iowa |
Tanya Perry |
Megan McIlhon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bobby Perry |
efpconstruction21@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Tanya Perry |
Megan McIlhon |
Signed |
775 |
2021-12-02 11:40 |
Anonymous (not verified) |
65.144.174.26 |
Pedro Campos |
Proprietorship |
16901 SW 13th 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. |
2021-12-02 |
Pedro Campos |
camposp113@msn.com |
Des Moines |
Polk |
IA |
Antonio Campos |
Daniel Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Campos |
camposp113@msn.com |
Self |
Des Moines |
Polk |
Iowa |
Antonio Campos |
Daniel Perez |
Signed |
781 |
2021-12-08 08:41 |
Anonymous (not verified) |
172.58.87.49 |
Diggins Installations |
Proprietorship |
1619 48th st 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. |
2021-12-06 |
Danny Allan Diggins |
ddigdan@gmail.com |
Des Moines |
Polk |
1619 48th st |
Nancy Davis |
Angie Pilcher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Danny Diggins |
ddigdan@gmail.com |
Self |
Des moines |
Polk |
Ia |
Nancy Davis |
Angie pilcher |
Signed |
785 |
2021-12-09 09:15 |
Anonymous (not verified) |
174.198.75.71 |
Daniel Vega camacho |
Proprietorship |
2415 river ,meadows drive 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. |
2021-12-09 |
Daniel Vega camacho |
dvega50265@gmail.com |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Vega camacho |
dvega50265@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
799 |
2021-12-15 11:48 |
Anonymous (not verified) |
74.84.79.78 |
Juan Martinez Slazar |
Proprietorship |
7085 Bloomfield Rd. Lot # 38 |
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 |
Juan A. Martinez Salazar |
juan50320@gmail.com |
Des Moines |
Polk |
Iowa |
Steve Young |
Logan Giudicessi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan A. Martinez Salazar |
juan50320@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Steve Young |
Logan Giudicessi |
Signed |
808 |
2021-12-20 12:28 |
Anonymous (not verified) |
107.77.209.143 |
Painting & Design |
Proprietorship |
2728 51st Des Moines Iowa 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. |
2021-12-20 |
John Eugene Herman |
jherman30@yahoo.com |
Des moines |
Polk |
Iowa |
Peggy Noplos |
Jennifer Herman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Herman |
jherman30@yahoo.com |
Self |
Des moines |
Polk |
Iowa |
Peggy Noplos |
Jennifer Herman |
Signed |
809 |
2021-12-21 14:42 |
Anonymous (not verified) |
75.162.173.166 |
Mike Money |
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. |
2021-12-21 |
Michael David Money |
poojennings78@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael David Money |
poojennings78@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
822 |
2022-01-04 16:59 |
Anonymous (not verified) |
173.22.62.131 |
Gerardo Calvillo |
Limited Liability Company |
1802 mondamin 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. |
2022-01-04 |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Aurora Maciel colín |
Gerardo Calvillo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Aurora maciel colín |
Gerardo Calvillo |
Signed |
853 |
2022-01-24 08:45 |
Anonymous (not verified) |
173.27.193.218 |
Matt ruble |
Limited Liability Company |
808 Grandview ave Des Moines Iowa 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. |
2022-01-23 |
Matthew ruble |
gmddetailing2012@gmail.com |
Des Moines |
Polk |
Iowa |
Matt Ruble |
Matt Ruble |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Ruble |
gmddetailing2012@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Matt Ruble |
Matt Ruble |
Signed |
876 |
2022-01-31 11:31 |
Anonymous (not verified) |
75.162.226.236 |
Leaf Fitters |
Limited Liability Company |
16180 SE Laurel St Des Moines Ia 50263 |
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. |
2022-01-31 |
Rogelio De La Rosa Jr. |
chucotx@rocketmail.com |
Des Moines |
Polk |
Iowa |
Noreen Henry |
Christian Lopez |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Rogelio De La Rosa |
chucotx@rocketmail.com |
self |
Des Moines |
polk |
ia |
noreen henry |
Christian Lopez |
Signed |
877 |
2022-01-31 11:43 |
Anonymous (not verified) |
75.162.226.236 |
Rogelio De La rosa |
Proprietorship |
2104 E 25th St. 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. |
2022-01-31 |
Rogelio De La rosa jr |
chucotx@rocketmail.com |
Des Moines |
polk |
Ia |
Noreen Henry |
Christian Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rogelio De La Rosa |
chucotx@rocketmail.com |
owner |
Des moines |
polk |
Ia |
Noreen Henry |
Christian Lopez |
Signed |
879 |
2022-01-31 14:26 |
Anonymous (not verified) |
173.27.146.201 |
Premier Window Cleaning LLC |
Limited Liability Company |
420 E GRANGER AVE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-31 |
Frank Viola |
premierofiowa@gmail.com |
DES MOINES |
IA |
United States |
Ron Reynolds |
Chris Greco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frank Viola |
premierofiowa@gmail.com |
my self |
DES MOINES |
IA |
United States |
Ron Reynolds |
Chris Greco |
Signed |
898 |
2022-02-04 21:46 |
Anonymous (not verified) |
107.77.161.27 |
Roger De La Rosa |
Proprietorship |
2104 E 25th 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. |
2022-02-04 |
Roger De La Rosa |
roger_dlr72@yahoo.com |
Des Moines |
Polk |
IA |
Noreen Henry |
Christian Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger De La Rosa |
roger_dlr72@yahoo.com |
Owner |
Des Moines |
Polk |
IA |
Noreen Henry |
Christian Lopez |
Signed |
906 |
2022-02-09 08:57 |
Anonymous (not verified) |
173.28.0.37 |
CAB Holdings LLC |
Limited Liability Company |
804 SE Cherry ST Ankeny, IA 50023 |
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. |
2022-02-09 |
Kristy Briles |
kristyabriles@gmail.com |
Des Moines |
Polk |
IA |
Stephanie Seymour |
Sue Briles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristy Briles |
kristyabriles@gmail.com |
owner |
Des Moines |
Polk |
IOwa |
Stephanie Seymour |
Sue Briles |
Signed |
907 |
2022-02-09 08:59 |
Anonymous (not verified) |
173.28.0.37 |
Rusty K5 LLC |
Limited Liability Company |
804 SW Cherry St Ankeny, IA 50023 |
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. |
2022-02-09 |
Kristy Briles |
kristyabriles@gmail.com |
Des Moines |
Polk |
IA |
Stephanie Seymour |
Sue Briles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristy Briles |
kristyabriles@gmail.com |
Owner |
Des moines |
Polk |
IA |
50313 |
Sue Briles |
Signed |
931 |
2022-02-21 15:04 |
Anonymous (not verified) |
69.18.14.11 |
Lawn's Plus |
Proprietorship |
6082 Northwest Beaver Drive, Johnston, Iowa 50131, United States |
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. |
2021-12-01 |
Javier Nieto |
jacobanderson55@yahoo.com |
Des Moines |
Polk |
Iowa |
Jacob Anderson |
Andrea Nieto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier Nieto |
jacobanderson55@yahoo.com |
Self |
Des Moiens |
Polk |
Iowa |
Jacob Anderson |
Andrea Nieto |
Signed |
941 |
2022-03-02 09:06 |
Anonymous (not verified) |
173.18.150.140 |
515 Trucking, L.L.C. |
Limited Liability Company |
4613 E Valdez Dr, 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. |
2022-03-02 |
Thomas L Garrett |
515TruckHaul@gmail.com |
Des Moines |
Polk |
Iowa |
Shelley L Garrett |
Sheila J Wyman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas L Garrett |
515TruckHaul@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Shelley L Garrett |
Sheila J Wyman |
Signed |
942 |
2022-03-02 18:52 |
Anonymous (not verified) |
173.16.196.70 |
Mason Cooper |
Limited Liability Company |
4213 Southwest 23rd Place |
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. |
2022-03-02 |
Mason Cooper |
koupenc5@icloud.com |
Des Moines |
Polk |
IA |
Savannah Cooper |
Norman Weathers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Cooper |
koupenc5@icloud.com |
Myself |
Des Moines |
Polk |
IA |
Savannah Cooper |
Norman Weathers |
Signed |