298 |
2020-10-30 10:45 |
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. |
2020-09-08 |
Gary 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. |
Gary Kregel |
TRAVIS.KREGEL@GMAIL.COM |
same |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
2008 |
2024-01-29 14:45 |
Anonymous (not verified) |
94.188.207.230 |
DB2P |
Limited Liability Company |
5904 Ashworth Road |
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 |
Arjun Dahal |
allcoolliquors@gmail.com |
West Des Moines |
Dallas |
Iowa |
Jayson Jones |
Nikki Wilks |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jayson Jones |
jayson@jonesinsured.com |
Insurance Agent |
Urbandale |
Dallas |
Iowa |
Jayson Jones |
Nikki Wilks |
Signed |
410 |
2021-02-19 09:23 |
Anonymous (not verified) |
166.181.84.153 |
Nikolai Charikov |
Proprietorship |
115 6th St NW |
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. |
2021-02-19 |
Nikolai Andre Charikov |
nikolaicharikov@gmail.com |
Mitchellville |
Polk |
Iowa |
Tyler Charikov |
Mile Hufford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nikolai Charikov |
nikolaicharikov@gmail.com |
Self |
Mitchellville |
Polk |
Iowa |
Tyler Charikov |
Mile Hufford |
Signed |
2120 |
2024-03-27 15:31 |
Anonymous (not verified) |
94.188.205.169 |
Dustin pleshe |
Proprietorship |
6855 woodland ave unit 505 |
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. |
2024-03-27 |
Dustin Pleshe |
dustinjpleshe@gmail.com |
WEST DES MOINES |
Iowa |
United States |
Kasey Cunningham |
Kathy Cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Pleshe |
dustinjpleshe@gmail.com |
He is me |
WEST DES MOINES |
Iowa |
United States |
Kasey cunningham |
Kathy cunningham |
Signed |
522 |
2021-05-17 20:27 |
Anonymous (not verified) |
50.81.4.25 |
Crew Cut Lawn Care |
Limited Liability Company |
7820 1st Ave NW Cedar Rapids, IA 52405 |
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 |
Rupert McKendly Ellis |
wideglide94@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Adrian Pink |
Lorraine Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rupert M Ellis |
wideglide94@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Adrian Pink |
Lorraine |
Signed |
937 |
2022-02-25 11:55 |
Anonymous (not verified) |
174.242.226.43 |
K3 Recycling |
Limited Liability Company |
510 West 2nd 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. |
2022-02-25 |
Justin Kappelman |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Kappelman |
justin@kappelmanappliance.com |
Same |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
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 |
1049 |
2022-04-14 14:29 |
Anonymous (not verified) |
72.13.27.253 |
Gudenkauf Underground llc |
Limited Liability Company |
1840 275th St Manchester Ia., 52057 |
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. |
2022-04-14 |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Self |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
746 |
2021-11-11 19:26 |
Anonymous (not verified) |
166.181.87.101 |
Joshua Duncan |
Proprietorship |
2237 west high street Davenport Iowa 52804 |
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. |
2021-11-11 |
Joshua Duncan |
Jduncan8669@gmail.com |
Davenport |
Scott |
Iowa |
Megan Ward |
Joseph Duncan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan Ward |
megward1986@gmail.com |
Fiancé |
Davenport |
Scott |
Iowa |
Megan Ward |
Joseph Duncan |
Signed |
1161 |
2022-06-22 19:41 |
Anonymous (not verified) |
208.38.229.190 |
Samuel Perez |
Proprietorship |
6523 N Main Street 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. |
(1) I am not electing the employers’ liability coverage. |
2022-06-22 |
Samuel Perez |
samuelperez@live.com |
Davenport |
Scott |
Iowa |
Raven Perez |
Omar Sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samuel Perez |
samuelperez@live.com |
Self |
Davenport |
Scott |
Iowa |
Raven Perez |
Omar Sanchez |
Signed |
858 |
2022-01-27 08:06 |
Anonymous (not verified) |
75.162.81.119 |
MR Custom Tile & Flooring LLC |
Limited Liability Company |
14390 Newbold Street, Indianola, IA, 50125 |
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 |
Matthew Royer |
royer20@yahoo.com |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Royer |
royer20@yahoo.com |
Myself |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
1273 |
2022-08-19 10:40 |
Anonymous (not verified) |
75.162.65.221 |
Robert Kilgore |
Proprietorship |
2404 34th St Des Moines 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. |
2022-08-19 |
Robert Kilgore |
robertkilgore1969@gmail.com |
Des Moines |
Polk |
Iowa |
Randy Lacine |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Kilgore |
robertkilgore1969@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1385 |
2022-12-08 18:45 |
Anonymous (not verified) |
173.26.84.6 |
Fansco LLC |
Limited Liability Company |
620 2 nd Ave SE Cresco IOWA 52136 |
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. |
2022-12-08 |
Arif Sheikh |
Sheikha44@yahoo.com |
Cresco |
Howard |
IOWA |
Bibi Sheikh |
Usman Sheikh |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Arif Sheikh |
Sheikha44@yahoo.com |
Relative |
Henderson |
Clark |
Navada |
Bibi Sheikh |
Usman Sheikh |
Signed |
1497 |
2023-03-07 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Holzworth Land Company |
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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-03-07 |
Victor Holzworth |
holzconstruction@gmail.com |
West Des Moines |
Polk |
Iowa |
Reid Tamisiea |
Mariah Burgett |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Victor Holzworth |
holzconstruction@gmail.com |
Owner |
West Des Moines |
Polk |
iowa |
Reid Tamisea |
Mariah Burgett |
Signed |
1609 |
2023-04-26 11:58 |
Anonymous (not verified) |
94.188.205.168 |
edwin gonzalez |
Proprietorship |
115 e ayers st osceola ia 50213 |
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. |
2023-04-26 |
edwin gonzalez |
lrestrada83@gmail.com |
osceola |
Clark |
ia |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
edwin gonzalez |
lrestrada83@gmail.com |
owner |
osceola |
clarke |
ia |
Sheanah Wright |
Derek Mullins |
Signed |
1721 |
2023-07-06 08:19 |
Anonymous (not verified) |
94.188.207.228 |
Bradford Alexander Carr |
Proprietorship |
3349 Southgate Ct SW Ste 101 |
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. |
2023-07-06 |
Bradford Alexander Carr |
alex.carr@thrivent.com |
Coralville |
Johnson |
Iowa |
Gaylon Heetland |
David King |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bradford Alexander Carr |
alex.carr@thrivent.com |
Self |
Coralville |
Johnson |
Iowa |
Gaylon Heetland |
David King |
Signed |
90 |
2020-03-13 15:44 |
Anonymous (not verified) |
173.24.190.134 |
Heath Householder |
Limited Liability Company |
2 N Huron 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. |
2020-01-07 |
Heath Householder |
heath679@live.com |
Emmetsburg |
Palo Alto |
Iowa |
Scott Wirtz |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Householder |
heath679@live.com |
Member of LLC |
Emmetsburg |
Palo Alto |
Iowa |
Scott Wirtz |
Candie Clark |
Signed |
1800 |
2023-08-14 20:24 |
Anonymous (not verified) |
94.188.207.227 |
Laven Snow Removal LLC |
Limited Liability Company |
413 SE 6th street Ankeny, IA 50021 |
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. |
2023-08-14 |
Myles John Laven |
lavensnowremoval@gmail.com |
Ankeny |
Polk |
Iowa |
Megan Rose Nefzger |
Mackale Joel Laven |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Myles John Laven |
lavensnowremoval@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Megan Rose Nefzger |
Mackale Joel laven |
Signed |
202 |
2020-07-10 15:30 |
Anonymous (not verified) |
50.82.95.247 |
Paulo De Oliveira |
Proprietorship |
466 Valeen In Belton, MO 64012 |
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. |
2020-07-10 |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
1912 |
2023-11-16 08:40 |
Anonymous (not verified) |
94.188.205.175 |
JC LANDSCAPING & LAWN CARE |
Proprietorship |
4940 E. SHERIDAN AVE DES MOINES, IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-16 |
CLAUDIA TORO PINEDA |
CLAUDIAMEP@HOTMAIL.COM |
DES MOINES |
POLK |
IA |
BRENDA REEDY |
ADAM SMITH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CLAUDIA TORO PINEDA |
CLAUDIAMEP@HOTMAIL.COM |
SELF |
DES MOINES |
POLK |
IA |
BRENDA REEDY |
ADAM SMITH |
Signed |
314 |
2020-11-13 10:18 |
Anonymous (not verified) |
66.172.192.197 |
Helaine W. Sherman Trust |
Proprietorship |
P.O. Box 717, Sioux City, Iowa 51102 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-13 |
Helaine W. Sherman Trust, A.F. Baron, Trustee |
afbaron@baronsar.com |
Sioux City |
Woodbury |
Iowa |
Joni L. Stieneke |
Gregory N. Lohr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Helaine W. Sherman Trust, A.F. Baron, Trustee |
afbaron@baronsar.com |
Trustee of Trust |
Sioux City |
Woodbury |
Iowa |
Joni L. Stieneke |
Gregory N. Lohr |
Signed |
2024 |
2024-02-06 20:31 |
Anonymous (not verified) |
94.188.207.223 |
BTS Custom Floors |
Proprietorship |
22 wenwood cir |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-06 |
Brandon Clay |
Brandon.btscustomfloors@gmail.com |
Council Bluffs |
Iowa |
United States |
Darin Thompson |
Amber Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Clay |
Brandon.btscustomfloors@gmail.com |
I am them |
Council Bluffs |
Iowa |
United States |
Amber Swanson |
Darin Thompson |
Signed |
426 |
2021-03-09 09:31 |
Anonymous (not verified) |
50.82.173.179 |
Joshua Strong DBA Watson Excavation |
Proprietorship |
202 Lewis St Bedford, IA 50833 |
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. |
2021-03-09 |
Joshua Strong |
joshandtanyastrong@yahoo.com |
Bedford |
Taylor |
IA |
Maggie Jackson |
Shella Baldwin |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tanya Strong |
tanya@farmandhomellc.com |
Spouse |
Bedford |
IA |
United States |
Maggie Jackson |
Shella Baldwin |
Signed |
2136 |
2024-04-04 16:08 |
Anonymous (not verified) |
94.188.205.169 |
Elite Construction & Masonry LLC |
Limited Liability Company |
3309 Wright 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. |
2024-04-04 |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
538 |
2021-06-08 16:59 |
Anonymous (not verified) |
66.188.136.150 |
John Sorrentino |
Proprietorship |
808 Dixie Dr. Enterprise, AL 36330 |
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 |
John Sorrentino |
kschumacher@tricorinsurance.com |
Enterprise |
Coffee |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Sorrentino |
kschumacher@tricorinsurance.com |
Same |
Enterprise |
Coffee |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
953 |
2022-03-07 16:13 |
Anonymous (not verified) |
173.27.196.168 |
Joel Cisneros |
Proprietorship |
721 e madison ave 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. |
2022-03-07 |
Joel Cisneros |
cisnerostile476@gmail.com |
Des monies |
Polk county |
Iowa |
Aurora Cisneros |
Romualda Ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Cisneros |
cisnerostile476@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Aurora Cisneros |
Romualda Ramos |
Signed |
650 |
2021-09-22 20:46 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services |
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 |
1065 |
2022-04-21 16:26 |
Anonymous (not verified) |
172.58.84.198 |
Royal Flooring |
Limited Liability Company |
11801 Hickman Rd Urbandale Iowa 50323 |
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. |
2022-04-21 |
Alondra Canedo Orta |
alondracanedo34@gmail.com |
Des Moines |
Polk county |
Iowa |
Alondra Canedo |
Marvin Bonilla |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Royal Flooring |
Workorders@shoproyalflooring.com |
Employee |
Des Moines |
Polk county |
Iowa |
Alondra Canedo |
Marvin Bonilla |
Signed |
762 |
2021-11-22 09:23 |
Anonymous (not verified) |
71.34.169.117 |
Oscar Lopez |
Proprietorship |
1175 Office Park Road Apt 109 West Des Moines, Iowa 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. |
2021-11-15 |
Oscar Lopez |
deb@piciowa.com |
WDM |
Polk |
ia |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Oscar Lopez |
deb@piciowa.com |
self |
WDM |
Polk |
IA |
Debra Stratton |
Kelly Denger |
Signed |
1177 |
2022-07-05 10:01 |
Anonymous (not verified) |
172.58.85.103 |
Leaf Guard |
Limited Liability Partnership |
3060 SE Grimes Blvd, suite 100 |
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. |
2022-07-04 |
Sean Gray |
Totaldemo94@gmail.com |
Des Moines |
Polk county |
Iowa |
Jeanie Lu |
Terra McAllister |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaffilter North LLC |
leaffilter@leafhome.com |
Worker |
Des moines |
Polk county |
IA |
Jeanie Lu |
Terra McAllister |
Signed |
874 |
2022-01-30 19:13 |
Anonymous (not verified) |
199.168.106.132 |
Pete Wilcox Trenching |
Proprietorship |
714 Main Street Cedar Falls IA 50613 |
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. |
2022-01-29 |
Peter Wilcox |
kwilcox@cfu.net |
Cedar Falls |
Black Hawk |
Iowa |
Terri Strein |
Marlene Rasmussen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
The Accel Group LLC |
info@acceladvantage.com |
customer |
Cedar Falls |
Black Hawk |
IA |
Terri Strein |
Marlene Rasmussen |
Signed |
1289 |
2022-09-01 11:06 |
Anonymous (not verified) |
104.222.95.52 |
Alliant Personnel Resources |
Limited Liability Company |
619 N Carroll St, Carroll, IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-01 |
Jonathan Sturm |
Jon@AlliantPR.com |
Carroll, IA |
Carroll County |
IA |
Sara Beiter |
Austin Scott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jon Sturm |
Jon@AlliantPR.com |
Owner |
Carroll, IA |
Carroll County |
Iowa |
Sara Beiter |
Austin Scott |
Signed |
1401 |
2022-12-23 09:07 |
Anonymous (not verified) |
75.162.43.221 |
Capital Express |
Limited Liability Company |
Council is Chris Blunk out of omaha NB. |
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. |
2021-09-09 |
Nicholas Michelfelder |
nicmichelfelder@gmail.com |
8018 Valdez Circle |
polk |
iowa |
Ted Michelfelder |
lucy Sanderson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Chris Blunk |
cblunk@harrislawomaha.com |
None |
1400 SE gateway Dr. 105 |
Polk |
IA |
Theodore Michelfelder |
Rick Isacson |
Signed |
1513 |
2023-03-13 06:54 |
Anonymous (not verified) |
94.188.205.169 |
Tyler Ankney |
Proprietorship |
1250 A Avenue, Marion, IA 52302, 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. |
2023-03-13 |
Tyler Ankney |
T_james55@ahoo.com |
Marion |
Linn County |
Iowa |
Jordan Nisiewicz |
Steve Gisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Steve Gisler |
Signed |
1625 |
2023-05-04 14:07 |
Anonymous (not verified) |
94.188.207.228 |
Extreme Repair, LLC |
Limited Liability Company |
300 North Carthage 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. |
2023-05-04 |
Tony Cleveland |
extremerepair1@yahoo.com |
EXIRA, IA |
Audubon |
United States |
Katherine Cleveland |
Isaac Kommes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Extreme Repai,r LLC |
extremerepair1@yahoo.com |
Self |
EXIRA, IA |
Audubon |
United States |
Katherine Cleveland |
Isaac Kommes |
Signed |
1737 |
2023-07-11 08:32 |
Anonymous (not verified) |
94.188.207.223 |
Scornos waukee llc |
Limited Liability Company |
286 w hickman rd waukee iowa 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. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
owner |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
106 |
2020-03-31 10:42 |
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 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
1816 |
2023-08-23 14:59 |
Anonymous (not verified) |
94.188.207.227 |
CHRIS PIERCE CONSTRUCTION LLC |
Proprietorship |
500 N 8th StAkron, IA 5100 |
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. |
2023-08-23 |
Chris Pierce |
chrispierceconstructionllc@gmail.com |
Akron |
Plymouth |
IA |
Susan Geist |
Paychex Insurance Agency |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Susan Geist |
sgeist@paychex.com |
Insurance Agency |
Rochester |
Monroe |
NY |
Susan Geist |
Paychex Insurance Agency |
Signed |
218 |
2020-07-27 19:24 |
Anonymous (not verified) |
174.217.10.15 |
Bella Exteriors LLC |
Limited Liability Company |
2908 Elm St, 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. |
2020-07-27 |
Nicholas Andersen |
nick@rightroofing.com |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Andersen |
nickande3564@gmail.com |
Self |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
551 |
2021-06-29 09:18 |
Anonymous (not verified) |
72.168.160.90 |
BERNARD WATERBECK |
Limited Liability Company |
1353 280TH STREET, GARWIN, IOWA 50632 |
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. |
2021-06-29 |
BERNARD WATERBECK |
garwinacres2012@hotmail.com |
GARWIN |
TAMA |
IOWA |
DEAN KELLER |
CESAR MARROQUIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BERNARD WATERBECK |
garwinacres2012@hotmail.com |
SAME PERSON |
GARWIN |
TAMA |
IOWA |
DEAN KELLER |
CESAR MARROQUIN |
Signed |
966 |
2022-03-11 10:04 |
Anonymous (not verified) |
173.19.189.168 |
Steger Siding & Construction |
Limited Liability Company |
1020 25th 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. |
2022-03-11 |
Jared Steger |
jared.steger@gmail.com |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Steger |
jared.steger@gmail.com |
self |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
663 |
2021-10-04 09:45 |
Anonymous (not verified) |
166.181.80.1 |
Matthew Winters |
Proprietorship |
9220 Summit Dr Johnston IA 50131 |
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. |
2021-10-04 |
Matthew Winters |
mattwinters55@gmail.com |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Winters |
mattwinters55@gmail.com |
Self |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
1078 |
2022-04-28 16:04 |
Anonymous (not verified) |
207.32.54.103 |
Juilfs Trucking |
Proprietorship |
709 S Geneva St. Pomeroy, IA 50575 |
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. |
2022-04-28 |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Pomeroy |
Calhoun |
Iowa |
Lorie Gerdes |
Autumn Ramthun |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Myself |
Pomeroy |
IA |
United States |
Lorie Gerdes |
Autumn Ramthun |
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 |
1190 |
2022-07-07 12:00 |
Anonymous (not verified) |
172.243.111.71 |
Breuer Earthworks Inc. |
Proprietorship |
4512 148th Ave Burlington, IA 52601 |
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. |
2022-07-07 |
William Breuer |
breuerearthworks@gmail.com |
Burlington |
Des Moines |
Iowa |
Donald Breuer |
Ericka Breuer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Breuer |
breuerearthworks@gmail.com |
Owner of Breuer Earthworks Inc. |
BURLINGTON |
Iowa |
United States |
Donald Breuer |
Ericka Breuer |
Signed |
1302 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
1414 |
2023-01-07 22:14 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Proprietorship |
18409 250th Street, 430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-07 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
1526 |
2023-03-21 12:24 |
Anonymous (not verified) |
94.188.207.223 |
Quad Cities Transport Inc |
Proprietorship |
1106 46th ave Rock Island IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-21 |
Howard Davis |
qctranaportinc@gmail.com |
East Moline |
Rock Island |
Illinois |
Ricky Oconner |
Patrick Watkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Howard Davis |
hdenterprisesinc14@gmail.com |
Owner |
East Moline |
Rock Island |
Illinois |
Patrick Watkins |
Ricky Oconner |
Signed |
1638 |
2023-05-11 07:33 |
Anonymous (not verified) |
94.188.205.177 |
HV Drywall LLC |
Proprietorship |
1991 Holiday Rd, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Jose Jesus Hernandez |
jh80292@gmail.com |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Jesus Hernandez |
jh80292@gmail.com |
self |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
7 |
2019-11-15 12:26 |
Anonymous (not verified) |
173.17.129.166 |
Thomas C. Davis |
Proprietorship |
3509 Franklin 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. |
2019-11-15 |
Thomas C. Davis III |
thomas.davis.iii@gmail.com |
Des Moines |
Polk |
Iowa |
Jared Vincent |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas C. Davis III |
thomas.davis.iii@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Jared Vincent |
Kevin Corn |
Signed |