731 |
2021-11-09 14:08 |
Anonymous (not verified) |
166.181.87.107 |
Leaf Filter North |
Limited Liability Company |
3060 SE Grimes Blvd, STE 100 Grimes, IA 50111 |
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 |
Jordan Cunningham |
jcunnsalvage@gmail.com |
Baxter |
Jasper |
Iowa |
Karen Cunningham |
Makenzie Raridon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan McIlhon |
mmcilhon@leaffilter.com |
Office Manager |
Grimes |
Polk |
Iowa |
Karen Cunningham |
Makenzie Raridon |
Signed |
1450 |
2023-02-11 10:59 |
Anonymous (not verified) |
94.188.205.168 |
JOSE G OLIVAREZ |
Limited Liability Company |
1529 11TH ST DES MOINES 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. |
2023-02-11 |
JOSE G OLIVAREZ |
joseolivares742@gmail.com |
DES MOINES |
POLK |
IOWA |
SAMIR RAHMANOVIC |
SAMIR RAHMANOVIC |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
none |
joseolivares742@gmail.com |
none |
DES MOINES |
POLK |
IOWA |
samir rahmanovic |
samir rahmanovic |
Signed |
843 |
2022-01-20 07:48 |
Anonymous (not verified) |
207.199.230.75 |
Heart of Iowa Inspections LLC |
Limited Liability Company |
2700 Highway 63 Oskaloosa, Iowa 52577 |
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. |
2022-01-20 |
Randy DeHeer |
rdenheer2828@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy DeHeer |
rdenheer2828@gmail.com |
self |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
1562 |
2023-04-10 07:43 |
Anonymous (not verified) |
94.188.205.174 |
JB Concrete and Construction |
Limited Liability Company |
306 1st Ave N.W Dayton 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. |
2023-04-10 |
JaredBerglund |
jaredberglund71@gmail.com |
Dayton |
Webster |
Iowa |
Travis Sonksen |
Chase Haman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JaredBerglund |
jaredberglund71@gmail.com |
Owner |
Dayton |
Webster |
Iowa |
Travis Sonksen |
Chase Haman |
Signed |
1674 |
2023-06-02 09:34 |
Anonymous (not verified) |
94.188.207.229 |
Kacena Family Tree Farm Inc |
Partnership |
2510 55th St., Vinton, IA 52349 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-01 |
Kyle Lynch |
kacenafarms.alyce@gmail.com |
Vinton |
Benton |
Iowa |
Ashlyn J. Christianson |
Angie McFarland |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alyce Lynch |
ashlyn@3riversins.net |
25% Owner - President |
Vinton |
Benton |
Iowa |
Ashlyn J. Christianson |
Angie McFarland |
Signed |
1865 |
2023-10-09 10:28 |
Anonymous (not verified) |
94.188.205.166 |
Lori Martinez |
Proprietorship |
6650 SE 5 TH STREET 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. |
2023-10-09 |
Lori Martinez |
azulbenavidez04@gmail.com |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Martinez |
azulbenavidez04@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
1977 |
2024-01-05 13:25 |
Anonymous (not verified) |
94.188.207.228 |
BOYOK BUILDS, LLC |
Limited Liability Company |
25395 140TH ST, SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-04 |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
75 |
2020-02-24 15:03 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho 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. |
2020-01-01 |
Ramiro Jurado Bucio |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
2089 |
2024-03-12 10:58 |
Anonymous (not verified) |
94.188.205.166 |
Margarito R Guzman |
Proprietorship |
4512 S 22nd ST Omaha NE 68107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-12 |
Margarito R Guzman |
abrahamguzman030@gmail.com |
omaha |
douglas |
NE |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Margarito Guzman |
abrahamguzman030@gmail.com |
Owner |
Omaha |
Douglas |
Nebraksa |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
187 |
2020-06-15 11:55 |
Anonymous (not verified) |
67.60.42.173 |
SANDS CONSTRUCTION LLC |
Limited Liability Company |
3812 Sioux River Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-06-15 |
Ryan Sands |
rn_sands@hotmail.com |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ryan Sands |
rn_sands@hotmail.com |
self/ Owner/ Operator |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
2201 |
2024-05-06 10:42 |
Anonymous (not verified) |
94.188.207.226 |
Trent Hatlen |
Proprietorship |
1042 490th Street, Rembrandt, IA 50576 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-06 |
Trent Hatlen |
trentgotti@yahoo.com |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trent Hatlen |
trentgotti@yahoo.com |
Owner |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
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 |
299 |
2020-10-30 10:47 |
Anonymous (not verified) |
216.51.132.207 |
Kregel Farm Partnership LLP |
Limited Liability Partnership |
30392 Garber RD Guttenberg, IA 52052 |
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 |
Darlene Kregel |
TRAVIS.KREGEL@GMAIL.COM |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darlene Kregel |
TRAVIS.KREGEL@GMAIL.COM |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
1018 |
2022-03-29 15:00 |
Anonymous (not verified) |
97.125.143.50 |
Modified Originals of Winterset |
Limited Liability Company |
128 S 3rd Ave, Winterset, IA 50273 |
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. |
2022-03-29 |
Daniel Maiers |
Modifiedoriginals.winterset@gmail.com |
Winterset |
Iowa |
Iowa |
Mark Haddinger |
Josh Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Maiers |
Modifiedoriginals.winterset@gmail.com |
Self |
Winterset |
Iowa |
Iowa |
Mark Haddinger |
Josh Williamson |
Signed |
411 |
2021-02-22 15:58 |
Anonymous (not verified) |
173.24.190.134 |
The Willow Tree Garden Center |
Limited Liability Company |
2103 19rh Street, Emmetsburg IA 50536 |
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. |
2021-02-22 |
Erica Janssen |
mrjanz13@gmail.com |
Emmetsburg |
Palo Alto |
Iowa |
Marilee Lace |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erica Janssen |
mrjanz13@gmail.com |
Member of LLC |
Emmetsburg |
Palo Alto |
Iowa |
Marilee Lace |
Candie Clark |
Signed |
1130 |
2022-05-26 13:34 |
Anonymous (not verified) |
172.58.227.18 |
Jonathan M Ramirez |
Proprietorship |
834 20th STREET SE. Cedar Rapids IA 53403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
Jonathan M Ramirez |
jon.hodgecma@gmail.com |
Cedar Rapids |
Linn |
IA |
Audrey Randle-EL |
Jeffrey M Ramirez Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Ramirez |
linncountyramirez@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Audrey Randle-EL |
Jeffrey Ramirez Jr |
Signed |
523 |
2021-05-17 21:46 |
Anonymous (not verified) |
173.29.90.123 |
Nick keppy |
Proprietorship |
2103 e Lombard st. Davenport 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. |
2021-05-17 |
Nick keppy |
keppylawncare@gmail.com |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca Hein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick keppy |
keppylawncare@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca hein |
Signed |
1242 |
2022-08-03 14:53 |
Anonymous (not verified) |
107.141.197.247 |
Hygieia Stainless Solutions LLC |
Limited Liability Company |
2200 Blairsferry Crossing Hiawatha, IA 52233 |
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. |
2022-08-03 |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
self |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
635 |
2021-09-10 13:41 |
Anonymous (not verified) |
166.181.84.226 |
JZH Roofing Specialists LLC |
Limited Liability Company |
2127 Swan Dr, Norwalk, Iowa. 50211 |
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 |
Jayme Alexander Christian Heiselman |
wrkhrd2plyhrd04@gmail.com |
Norwalk |
Warren |
Iowa |
Melanie Handy |
Jesse Hagge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jayme Alexander Christian Heiselman |
wrkhrd2plyhrd04@gmail.com |
Single member |
Norwalk |
Warren |
Iowa |
Melanie Handy |
Jesse Hagge |
Signed |
1354 |
2022-11-01 05:31 |
Anonymous (not verified) |
75.162.229.216 |
Brad Sommers Construction, LLC. |
Limited Liability Company |
23653 N Ave, Dallas Center, Iowa 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
Brad Sommers |
Bsconst1@gmail.com |
Dallas Center |
Dallas |
Iowa |
Ben Sommers |
Keith Winey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brad Sommers |
Bsconst1@gmail.com |
owner |
Dallas Center |
Dallas |
Iowa |
Ben Sommers |
Keith Winey |
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 |
1466 |
2023-02-17 15:12 |
Anonymous (not verified) |
94.188.207.230 |
BIG Roofing, LLC |
Limited Liability Company |
5751 NE 22nd St. #304 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. |
2023-02-17 |
Tyler Jeffrey Baugh |
tj@bigroofing515.com |
Lincoln |
Lancaster |
Nebraska |
Steven Bieghler |
Andrew John Kohles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Craig Bieghler |
steve@bigroofing515.com |
Owner |
Cumming |
Dallas |
Iowa |
Tyler Jeffrey Baugh |
Andrew John Kohles |
Signed |
859 |
2022-01-27 11:29 |
Anonymous (not verified) |
204.155.61.217 |
JD Drywall |
Proprietorship |
503 9th Street Kalona, Iowa 52247 |
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. |
2022-01-27 |
John Duwa |
johnduwa@outlook.com |
Kalona |
Washington |
Iowa |
Angela Stutzman |
Jeff Spenner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JD Drywall - John Duwa |
johnduwa@outlook.com |
owner |
Kalona |
Washington |
Iowa |
Angela Stutzman |
Jeff Spenner |
Signed |
1578 |
2023-04-17 15:33 |
Anonymous (not verified) |
94.188.205.174 |
Spark Train Express LLC |
Limited Liability Company |
16877 500th St, Pocahontas, IA 50574 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Austin Sparks |
sparksaustin.11@gmail.com |
Pocahontas |
Pocahontas |
Iowa |
Stephanie Webbink |
Christian Lynch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Sparks |
sparksaustin.11@gmail.com |
Owner |
Pocahontas |
Pocahontas |
Iowa |
Stephanie Webbink |
Christian Lynch |
Signed |
1690 |
2023-06-13 20:01 |
Anonymous (not verified) |
94.188.207.227 |
Gerardo Reyes-Lopez |
Limited Liability Company |
908 West 1st Street, Waterloo, Iowa, 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-13 |
Gerardo Reyes-lopez |
bernardo@reyesconstruct.com |
Waterloo |
IA |
United States |
Guillermina Lopez |
Bernardo Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Denise Seitsinger |
denise@harmsinsuranceagency.com |
Insurance Agent |
Sumner |
Bremer |
Iowa |
Gerardo Reyes |
Bernardo Reyes |
Signed |
1769 |
2023-07-31 11:23 |
Anonymous (not verified) |
94.188.207.228 |
PSI LLC |
Limited Liability Company |
2765 N Center Point Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-31 |
Esteici Reyes |
stacy0979@gmail.com |
Cedar Rapids |
Linn |
IA |
Jeffrey Ventura |
Eduardo Contreras |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Esteici Reyes |
stacy0979@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Jeffrey Ventura |
Eduardo Contreras |
Signed |
1881 |
2023-10-26 14:10 |
Anonymous (not verified) |
94.188.205.175 |
McAninch Painting LLC |
Limited Liability Company |
2422 Richmond Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
Brian McAninch |
brian@allcoatfinishes.com |
Des Moines |
Polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian McAninch |
brian@allcoatfinishes.com |
Self |
Des Moines |
polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
1993 |
2024-01-23 07:36 |
Anonymous (not verified) |
94.188.205.168 |
Leaf Home Solutions LLC |
Limited Liability Partnership |
1595 Georgetown Road Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-23 |
Michael Rice |
wildblueed@gmail.com |
Middle Amana |
Iowa |
Iowa |
Sylvia Rice |
Russel Hospadarsky |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Acosta |
macosta@leafhome.com |
recruiter |
Hudson |
Summit |
Ohio |
Sylvia Rice |
Russel Hospadarsky |
Signed |
91 |
2020-03-13 15:51 |
Anonymous (not verified) |
173.24.190.134 |
Small Town RV, LLC |
Limited Liability Company |
112 Miller 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. |
2020-03-09 |
Heath Sabin |
sales@smalltownrv.com |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Sabin |
sales@smalltownrv.com |
Member of LLC |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
2105 |
2024-03-18 12:45 |
Anonymous (not verified) |
94.188.205.169 |
Scornos Altoona LLC |
Proprietorship |
2437 adventureland dr altoona iowaa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
203 |
2020-07-15 09:39 |
Anonymous (not verified) |
166.181.66.222 |
High Caliber Fiber |
Limited Liability Company |
2958 110th ave masonville IA, 50654 |
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. |
2020-07-15 |
Chris cooper |
chris_cooper@highcaliberfiber.com |
Masonville |
Delaware |
Iowa |
Nick beranek |
Nicole kintzle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
chris_cooper@highcaliberfiber.com |
N/A |
Masonville |
Delaware |
Iowa |
Nick beranek |
Nicole kintzle |
Signed |
2217 |
2024-05-09 14:28 |
Anonymous (not verified) |
94.188.207.224 |
Emmanual A Sanchez Chavez |
Proprietorship |
7301 Fleur Dr, Lot 10, Des Moines, 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. |
2024-05-09 |
Emmanuel A Sanchez Chaves |
alexsanchw3@gmail.com |
Des Moines |
Polk |
Iowa |
Jesus Garcia |
Fabion Dalgato |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emmanuel A Sanchez Chavez |
alexsanchw3@gmail.com |
Person |
Des Moines |
Polk |
Iowa |
Jesus Garcia |
Fabion Dalgato |
Signed |
922 |
2022-02-17 12:44 |
Anonymous (not verified) |
173.22.55.191 |
Red Rock Hunt Club |
Limited Liability Company |
1730 All State Ct. Suite 100 West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Victor Holzworth |
holzconstruction@gmail.com |
Waukee |
Dallas |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Holzworth |
holzconstruction@gmail.com |
Owner |
West Des Moines |
Polk |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
315 |
2020-11-13 10:48 |
Anonymous (not verified) |
66.188.136.150 |
Jessie Spurlin |
Proprietorship |
58977 Al Hwy 77, Talladega, AL 35160 |
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. |
2020-11-11 |
Jessie Spurlin |
kschumacher@tricorinsurance.com |
Talladega |
Talladega |
AL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jessie Spurlin |
kschumacher@tricorinsurance.com |
Same |
Talledaga |
Talledaga |
AL |
Russell Masartis |
Nancy Wortley |
Signed |
1034 |
2022-04-05 11:43 |
Anonymous (not verified) |
75.162.133.214 |
Riftworks Wood Manufactory |
Proprietorship |
3807 Adams Ave, 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. |
2022-04-05 |
Bryan Siever |
bryan@siever.us |
Des Moines |
IA |
United States |
Cakeb Payne |
Tyler Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryan siever |
bryan@siever.us |
Business owner |
Des Moines |
IA |
United States |
Caleb Payne |
Tyler Anderson |
Signed |
427 |
2021-03-10 11:52 |
Anonymous (not verified) |
66.188.136.150 |
Ronald Tessen |
Proprietorship |
493 Hill St. Green Lake, WI 54941 |
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 |
Ronald Tessen |
kschumacher@tricorinsurance.com |
Green Lake |
Green Lake |
WI |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald Tessen |
kschumacher@tricorinsurance.com |
Same |
Green Lake |
Green Lake |
WI |
Russell Masartis |
Amanda Seeberger |
Signed |
1146 |
2022-06-07 11:51 |
Anonymous (not verified) |
173.27.226.177 |
Evans Endeavors LLC |
Limited Liability Company |
513 N Roche St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-07 |
Cody Evans |
evansendeavor@gmail.com |
Knoxville |
Marion |
Iowa |
Erin Six |
Carl stoffer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Evans |
evansendeavor@gmail.com |
Myself |
Knoxville |
Marion |
Iowa |
Erin six |
Carl Stoffer |
Signed |
539 |
2021-06-08 17:06 |
Anonymous (not verified) |
66.188.136.150 |
Todd Sechler |
Proprietorship |
505 5th Street Wellman, IA 52356 |
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. |
2021-06-08 |
Todd Sechler |
kschumacher@tricorinsurance.com |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Sechler |
kschumacher@tricorinsurance.com |
Same |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
1258 |
2022-08-15 13:30 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd St., Davenport, IA 52806 |
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. |
2022-08-15 |
George Anthony Loeffelholz |
tobby.loeffelholz@gmail.com |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
651 |
2021-09-22 21:05 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services LLC |
Limited Liability Company |
6285 n 67 ave w. BAXTER IOWA 50028 |
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. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
1370 |
2022-11-13 19:49 |
Anonymous (not verified) |
174.213.144.30 |
Iowa’s Gutter Specialist |
Limited Liability Company |
1390 Lark 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. |
2022-10-21 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Patricia Reynolds |
Heather Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Patricia Marie Reynolds |
Heather Marie Halverson |
Signed |
763 |
2021-11-22 12:32 |
Anonymous (not verified) |
63.229.189.35 |
Adam Dotson Tiling |
Proprietorship |
324 E 14th Street, Spencer, IA 51301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Adam Dotson |
adamdotson1975@gmail.com |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Dotson |
adamdotson1975@gmail.com |
Self |
Spencer |
Clay |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
1482 |
2023-02-24 13:57 |
Anonymous (not verified) |
94.188.205.175 |
Vaughn Seeds, LLC |
Limited Liability Company |
5025 13th Ave, La Porte City, IA 50651 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-24 |
Brice Jacob Vaughn |
brice.vaughn1@gmail.com |
La Porte Citty |
Benton |
Iowa |
Abby Jo Rolston |
Jessica Lyn McCabe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Rolston |
arolston@hagerins.net |
Insured |
La Porte City |
Black Hawk |
Iowa |
Jessica Lyn McCabe |
Russell Britson |
Signed |
875 |
2022-01-31 11:00 |
Anonymous (not verified) |
173.31.102.93 |
Jhk Construction LLC |
Limited Liability Company |
6203 Casey Ct NE cedar Rapids Iowa 52411 |
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 |
Edward Charles Loehr |
jhkcostruction10@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Leanne M Loehr |
Autumn G Loehr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jhk Construction LLC |
jhkconstruction10@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Leanne M Loehr |
Autumn G Loehr |
Signed |
1594 |
2023-04-24 10:06 |
Anonymous (not verified) |
94.188.205.175 |
Joseph Hatton |
Proprietorship |
85 Cardinal Ave, Atkins , 52206, 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. |
2023-04-24 |
Joseph Hatton |
joeyh697@gmail.com |
Atkins |
Benton County |
Iowa |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Robert Snyder |
Signed |
1706 |
2023-06-23 17:32 |
Anonymous (not verified) |
94.188.205.169 |
pro plumbing and heating llc |
Limited Liability Company |
109 w market st, po box 205 saint charles ia 50240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-23 |
lee douglas kearney |
ankenypro@gmail.com |
saint charles |
madison |
iowa |
sheila may kearney |
madison grace kearney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
lee d kearney |
ankenypro@gmail.com |
owner |
saint charles |
madison |
iowa |
sheila may kearney |
madison grace kearney |
Signed |
1785 |
2023-08-06 17:37 |
Anonymous (not verified) |
94.188.207.225 |
J and B Zuck Trucking LLC |
Limited Liability Company |
7310 E Airline Hwy Dunkerton, IA 50626 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-08 |
Justin Zuck |
jandbzucktrucking@gmail.com |
DUNKERTON |
Iowa |
United States |
Justin Zuck |
Rebekah Zuck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Zuck |
jandbzucktrucking@gmail.com |
owner |
DUNKERTON |
Iowa |
United States |
Justin Zuck |
Rebekah Zuck |
Signed |
1897 |
2023-11-06 09:12 |
Anonymous (not verified) |
94.188.205.177 |
Matthew Jones |
Limited Liability Company |
124 NE 49th 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. |
2023-11-06 |
Matthew Jones |
mjj4242@gmail.com |
Ankeny |
Polk |
IA |
Duan Willform |
AJ Giebelstein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Jones |
mjj4242@gmail.com |
Self |
Ankeny |
Polk |
IA |
AJ Giebelstein |
Duan Willform |
Signed |
2009 |
2024-01-29 22:59 |
Anonymous (not verified) |
94.188.207.226 |
Kimberly Ruby Reyes Victoriano |
Proprietorship |
1910 Eric 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. |
2024-01-29 |
Kimberly Ruby Reyes Victoriano |
InOnePieceDrywall@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Juan Jose Victoriano Ramirez |
Denir Billy Flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Ruby Reyes Victoriano |
InOnePieceDrywall@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Juan Jose Victoriano Ramirez |
Fredy Perez Perez |
Signed |
107 |
2020-03-31 10:47 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-31 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |