2022 |
2024-02-02 12:24 |
Anonymous (not verified) |
94.188.205.175 |
Short's Lawn Care LLC. |
Limited Liability Company |
309 2ND ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-02 |
Mike Short |
Shortslawns@gmail.com |
REDFIELD |
IA |
United States |
Michael Thomas Short |
Michael Short |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Short |
Shortslawns@gmail.com |
Owner |
REDFIELD |
IA |
United States |
Michael Thomas Short |
Michael Short |
Signed |
2021 |
2024-02-02 10:12 |
Anonymous (not verified) |
94.188.207.227 |
JUSIC ENTERPRISES LLC DBA MJS TREE SERVICE |
Limited Liability Company |
11619 NW 106TH AVE GRANGER, IA 50109 |
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. |
2024-02-02 |
MERSUDIN JUSIC |
MERSO.JUSIC@GMAIL.COM |
GRANGER |
POLK COUNTY |
IOWA |
RICHARD BALES |
ZACHARY SMITH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MERSUDIN JUSIC |
MERSO.JUSIC@GMAIL.COM |
MEMBER OWNER |
GRANGER |
POLK |
IOWA |
RICH BALES |
ZACHARY SMITH |
Signed |
2020 |
2024-02-02 07:14 |
Anonymous (not verified) |
94.188.207.230 |
SM4 Consulting LLC |
Limited Liability Company |
503 E 6TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-02 |
Chad Smith |
sm4consultingllc@gmail.com |
PRAIRIE CITY |
Jasper |
Iowa |
Nicole Smith |
Maybelle Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Smith |
sm4consultingllc@gmail.com |
self |
PRAIRIE CITY |
Jasper |
Iowa |
Nicole Smith |
Maybelle Smith |
Signed |
2019 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.167 |
SolQ LLC |
Limited Liability Company |
184 N 100 E STE A Logan, UT 84321 |
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. |
2024-02-01 |
wyatt phelps |
wyatt@solq.com |
Eagle Mountain |
UT |
United States |
Perry M Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
wyatt phelps |
wyatt@solq.com |
Owner |
Eagle Mountain |
UT |
United States |
Perry M Koker |
Rebecca Koger |
Signed |
2018 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.177 |
SolQ, LLC |
Limited Liability Company |
184 N 100 E STE A Logan, UT 84321 |
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. |
2024-02-01 |
David Bean |
dave@solq.com |
Clarkston |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Bean |
dave@solq.com |
Owner |
Logan |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
2017 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.174 |
SolQ, LLC |
Limited Liability Company |
184 N 100 E Suite A Logan UT 84321 |
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. |
2024-02-01 |
Casey Ryan Winger |
casey@solq.com |
Providence |
Cache |
UT |
Perry M. Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casey Ryan Winger |
casey@solq.com |
Owner |
Providence |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
2016 |
2024-02-01 09:20 |
Anonymous (not verified) |
94.188.207.225 |
Imperium Outdoor Solutions |
Proprietorship |
114 W Clanton St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-01 |
Austin Beener |
abeener033@gmail.com |
St Charles |
IA |
United States |
Austin Beener |
Austin Beener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Beener |
abeener033@gmail.com |
Operator |
St Charles |
IA |
United States |
Austin Beener |
Austin Beener |
Signed |
2015 |
2024-02-01 08:26 |
Anonymous (not verified) |
94.188.207.223 |
Salazar Builders inc |
Proprietorship |
29175 365th st van meter 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. |
2024-02-01 |
José Luis ángeles Salazar |
salazarbuilders15@gmail.com |
Van meter ia |
Dallas |
Iowa |
Adam Paul Boge |
Lance Owen Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Luis angeles Salazar |
salazarbuilders15@gmail.com |
Sub contractor |
Van meter |
Dallas |
Iowa |
Adam Paul Boge |
Lance Owen Webster |
Signed |
2014 |
2024-01-31 15:17 |
Anonymous (not verified) |
94.188.205.174 |
Aspen Ridge LLC |
Limited Liability Company |
1404 G Avenue |
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. |
2023-05-10 |
Lori McKusker |
lori@mckuskerelectric.com |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori McKusker |
jeff@mckuskerelectric.com |
Self |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
2013 |
2024-01-31 15:14 |
Anonymous (not verified) |
94.188.205.167 |
Aspen Ridge LLC |
Limited Liability Company |
1404 G Ave Marengo, IA 52301 |
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. |
2023-05-10 |
Jeffrey McKusker |
jeff@mckuskerelectric.com |
Marengo |
Iowa |
Iowa |
Karly Kovar |
Jacob McKusker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori McKusker |
jeff@mckuskerelectric.com |
Spouse |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
2012 |
2024-01-31 10:38 |
Anonymous (not verified) |
94.188.207.228 |
Mathew Soulis |
Proprietorship |
618 Boston Drive, 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. |
2023-01-31 |
Mathew Soulis |
mathew.soulis@gmail.com |
Davenport |
Scott |
IA |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
JNisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
MO |
Cody Dunbar |
Monica Acosta |
Signed |
2011 |
2024-01-31 07:01 |
Anonymous (not verified) |
94.188.205.166 |
Goede Mechanical |
Limited Liability Company |
1607 10th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-31 |
Don Goede |
goedemechanical@gmail.com |
Harlan |
Shelby |
Iowa |
Dylan Goede |
Kallie Goede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Don Goede |
goedemechanical@gmail.com |
Owner |
Harlan |
Shelby |
Iowa |
Dylan Goede |
Kallie Goede |
Signed |
2010 |
2024-01-30 11:46 |
Anonymous (not verified) |
94.188.207.230 |
Kevin & Jlynn Jones |
Proprietorship |
1500 15th St. Milford Ia 51351 |
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. |
2024-01-30 |
Jlynn Jones |
KEVINMJONES81@GMAIL.COM |
Milford |
Dickinson |
Iowa |
Tami Klein |
Joseph Loring |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin & Jlynn Jones |
KEVINMJONES81@GMAIL.COM |
Self |
Milford |
Dickinson |
Iowa |
Tami Klein |
Joseph Loring |
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 |
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 |
2007 |
2024-01-29 13:13 |
Anonymous (not verified) |
94.188.205.174 |
Saratoga Seamless Gutters LLC |
Limited Liability Company |
10328 Howard Ave, Lime Springs, IA 52155 |
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 |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Owner |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |
2006 |
2024-01-29 11:04 |
Anonymous (not verified) |
94.188.207.224 |
Kevin Jones |
Proprietorship |
1500 15Th St. Milford IA 51351 |
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 |
KEVIN JONES |
KEVINMJONES81@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEVIN JONES |
KEVINMJONES81@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
2005 |
2024-01-29 08:50 |
Anonymous (not verified) |
94.188.207.226 |
Laser Line Striping |
Proprietorship |
10572 320th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-29 |
Dean Weikert |
d.lineuponline@yahoo.com |
Ackley |
Iowa |
United States |
Linda Weikert |
Ca |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kain Helmke |
d.lineuponline@yahoo.com |
D.lineuponline@yahoo.com |
Ackley |
Butler |
Iowa |
Linda Weikert |
Kain Helmke |
Signed |
2004 |
2024-01-28 12:41 |
Anonymous (not verified) |
94.188.205.174 |
Wasabi Urbandale LLC |
Limited Liability Company |
5106 155th Street, Urbandale, IA 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. |
2024-01-28 |
Yean Ching Sue |
soamie@hotmail.com |
Urbandale |
Dallas |
Iowa |
Lina Zheng |
Jenna Yu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Yean Ching Sue |
soamie@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Lina Zheng |
Jenna Yu |
Signed |
2003 |
2024-01-28 12:38 |
Anonymous (not verified) |
94.188.205.169 |
Wasabi Urbandale LLC |
Limited Liability Company |
2301 Rocklyn Dr, Urbandale IA 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
Dallas |
IA |
Ajdin Nadarich |
Jeremy Boysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
Self |
Clive |
Dallas |
IA |
Lisa Lee |
Yingna Zheng |
Signed |
2002 |
2024-01-26 17:00 |
Anonymous (not verified) |
94.188.207.228 |
Legacy Group Consulting |
Limited Liability Company |
3721 Coppermill Rd NE, Cedar Rapids, IA 52402 |
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. |
2024-01-26 |
John A Scott |
legacygrpconsulting@gmail.com |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John A Scott |
legacygrpconsulting@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
2001 |
2024-01-26 10:41 |
Anonymous (not verified) |
94.188.207.225 |
4 Sons Splicing & Activation |
Proprietorship |
13510 W Brazos Bend Dr, Needville, TX 77461-9525 |
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. |
2024-01-26 |
John Kevin Steil |
foursons1990@steil.org |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Helen Frances Steil |
foursons1990@steil.org |
Spouse |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
2000 |
2024-01-26 10:05 |
Anonymous (not verified) |
94.188.205.177 |
Nick Myers Construction |
Proprietorship |
4736 Candlewick Drive, Norwalk, IA 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. |
2024-01-26 |
Nicholas Myers |
myersnicholasj@gmail.com |
Norwalk |
Warren |
Iowa |
John Myers |
Brenda Myers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Myers |
nickmyersconstruction@gmail.com |
Owner |
Norwalk |
IA |
IA |
John Myers |
Brenda Myers |
Signed |
1999 |
2024-01-25 16:57 |
Anonymous (not verified) |
94.188.205.177 |
Nicholas Schaff |
Limited Liability Company |
6934 rolling ridge ct sw cedar rapids Iowa 52404 |
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. |
2024-01-25 |
Nicholas Schaff |
schaff.lawncare@gmail.com |
cedar rapids |
linn |
iowa |
Brian Zeller |
Cassie Schaff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas schaff |
schaff.lawncare@gmail.com |
Same person |
cedar rapids |
iowa |
iowa |
Brian zeller |
cassie schaff |
Signed |
1998 |
2024-01-25 16:18 |
Anonymous (not verified) |
94.188.205.168 |
Faith and Trust Soulutions LLC |
Limited Liability Company |
139 37th Street NE Suite # 2 |
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. |
2024-01-25 |
Marie Moore |
faithandtrustsoulutionsllc@gmail.com |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arthur Barbine |
faithandtrustsoulutionsllc@gmail.com |
Friend |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
1997 |
2024-01-25 11:09 |
Anonymous (not verified) |
94.188.207.225 |
Abstract Associates of Iowa Inc. |
Proprietorship |
822 Central Ave Ste 304 Fort Dodge, IA 50501 |
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. |
2023-09-21 |
Ted Hugghins |
tjhugghins@abstractassociatesofiowa.com |
Fort Dodge |
Webster |
Iowa |
Mariah Ayala |
Bennett O'Connor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Hugghins |
tjhugghins@abstractassociatesofiowa.com |
President |
Fort Dodge |
Webster |
IA |
Mariah Ayala |
Bennett O'Connor |
Signed |
1996 |
2024-01-24 10:30 |
Anonymous (not verified) |
94.188.207.224 |
E&p quality home remodeling llc |
Limited Liability Company |
2660 NE 44th ct desmoines 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. |
2024-01-24 |
Pedro martinez |
pmsalas82@gmail.com |
Des Moines |
Polk |
Iowa |
Rogelio martinez |
Rigoberto martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Martinez |
pmsalas82@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Rogelio Martínez |
Rigoberto Martínez |
Signed |
1995 |
2024-01-23 15:08 |
Anonymous (not verified) |
94.188.205.167 |
Spencer Abbott |
Proprietorship |
1358 170th Ave, Murray Iowa 50174 |
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 |
Spencer Abbott |
sabbott1800@gmail.com |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Abbott |
sabbott1800@gmail.com |
sole proprietor |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
1994 |
2024-01-23 14:35 |
Anonymous (not verified) |
94.188.207.229 |
Josh Oswald |
Proprietorship |
505 Eisenhower Rd., 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. |
2024-01-23 |
Josh Oswald |
jjoswald47@gmail.com |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOSHUA OSWALD |
jjoswald47@gmail.com |
Sole Proprietor |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
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 |
1992 |
2024-01-18 21:51 |
Anonymous (not verified) |
94.188.205.175 |
NB Tile |
Proprietorship |
13310 NE 112th ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-18 |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Maxwell |
IA |
United States |
Kevin Orr |
Sydney Paustian |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Owner |
Mawell |
Polk |
Iowa |
Kevin Orr |
Sydney Paustian |
Signed |
1991 |
2024-01-17 00:34 |
Anonymous (not verified) |
94.188.207.223 |
Wasabi urbandale llc |
Limited Liability Company |
7115 Ridgedale ct, 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. |
2024-01-17 |
Wenhui chen |
michaelchen@wasabidsm.com |
Johnston |
Polk |
Iowa |
Yilian lin |
Ji jie jie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wenhui chen |
michaelchen@wasabidsm.com |
Owner |
Johnston |
Polk |
Iowa |
Yilian lin |
Ji jie jie |
Signed |
1990 |
2024-01-16 22:22 |
Anonymous (not verified) |
94.188.205.168 |
DeltaPro Painting & Remodeling |
Limited Liability Company |
1115 Nolan Court North Liberty 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. |
2024-01-16 |
Bayron Amador |
bayronamador59@gmail.com |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bayron Amador |
bayronamador59@gmail.com |
Owner/Employer |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
1989 |
2024-01-16 17:13 |
Anonymous (not verified) |
94.188.205.168 |
Xcel Electric LLC |
Limited Liability Company |
1142 Columbus Dr Waterloo 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. |
2024-01-16 |
Haris Mumic |
h.mumic@hotmail.com |
Waterloo |
Black Hawk |
IA |
Minea Skrgic-Mumic |
Elvis Mumic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Haris Mumic |
h.mumic@hotmail.com |
Owner/Employer |
waterloo |
Black Hawk |
IA |
Minea Skrgic-Mumic |
Elvis Mumic |
Signed |
1988 |
2024-01-16 15:22 |
Anonymous (not verified) |
94.188.205.176 |
Harmons Home Services LLC |
Limited Liability Company |
605 w Cedar st, Cherokee, IA, 51012 |
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. |
2024-01-16 |
Shawn Michael Harmon |
harmonsheatingandair@gmail.com |
Cherokee |
Ia |
United States |
Shawn Harmon |
Sara Harmon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Michael Harmon |
Harmonsheatingandair@gmail.com |
Self |
Cherokee |
Cherokee |
IA |
Shawn Harmon |
Sara Harmon |
Signed |
1987 |
2024-01-16 12:35 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi urbandale LLc |
Limited Liability Company |
12509 Townsend Ava, Urbandale, IA 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. |
2024-01-16 |
Wen Zheng |
jenna18841002@hotmail.com |
Urbandale |
Dallas |
Iowa |
Jie Li |
Yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wen Zheng |
jenna18841002@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowas |
Jie Li |
Yingna zheng |
Signed |
1986 |
2024-01-16 12:18 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi Urbandale LLC |
Limited Liability Company |
2965 Se Timberline dr , 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. |
2024-01-16 |
Enjinzheng |
jimmyzheng1573@gmail.com |
Waukee |
Dallas |
Iowa |
Jie Li |
Yingnazheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enjin zheng |
jimmyzheng1573@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Jie Li |
Yingna zheng |
Signed |
1985 |
2024-01-16 11:51 |
Anonymous (not verified) |
94.188.205.167 |
Wasabi Urbandale LLC |
Limited Liability Company |
5106 155th Street, Urbandale, IA 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. |
2024-01-16 |
Yean Ching Sue |
soamie@hotmail.com |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yean Ching Sue |
soamie@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
1984 |
2024-01-15 17:33 |
Anonymous (not verified) |
94.188.207.227 |
Jay Wang |
Limited Liability Company |
8481 Birchwood Ct, Johnston |
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. |
2024-01-15 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
US |
IA |
Yingna Zheng |
Qiaoqiao Li |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
Self |
Clive |
US |
IA |
Yingna Zheng |
Qiaoqiao Li |
Signed |
1983 |
2024-01-11 13:02 |
Anonymous (not verified) |
94.188.205.168 |
r&k propety solutions |
Proprietorship |
po box 53 cedar rapids iowa 52406 |
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. |
2024-01-11 |
roy rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
ia |
Brian Ashlock |
tim vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Center Point |
Benton |
ia |
Tim Vaske |
Roy Rohwedder |
Signed |
1982 |
2024-01-11 12:29 |
Anonymous (not verified) |
94.188.205.166 |
Grace Justine |
Proprietorship |
405 Northview Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
own |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
1981 |
2024-01-10 22:12 |
Anonymous (not verified) |
94.188.205.175 |
Level Up Renovations LLC |
Limited Liability Company |
648 31st Street, Des Moines, IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-10 |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Owner |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
Signed |
1980 |
2024-01-10 11:32 |
Anonymous (not verified) |
94.188.207.224 |
Raudel Correa |
Proprietorship |
1924 23rd St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Raudel Correa |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raudel Correa |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
1979 |
2024-01-08 14:59 |
Anonymous (not verified) |
94.188.205.167 |
Nathan Troendle |
Proprietorship |
Lansing 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. |
2024-01-05 |
Nathan Troendle |
darrele@ciains.biz |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Troendle |
darrele@ciains.biz |
self |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1978 |
2024-01-08 13:28 |
Anonymous (not verified) |
94.188.205.167 |
TYREL GIBSON |
Proprietorship |
2004 CHICAGO AVE 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. |
2024-01-08 |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
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 |
1976 |
2024-01-04 15:48 |
Anonymous (not verified) |
94.188.207.224 |
Brawdy Services |
Proprietorship |
7029 Prairie 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. |
2024-01-01 |
Victor Brawdy |
heather.l.brawdy@gmail.com |
Urbandale |
Polk |
IA |
Summer Munoz |
Jennifer Wolters |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Brawdy |
vb69ia@gmail.com |
Self |
Urbandale |
Polk |
IA |
Summer Munox |
Jennifer Wolters |
Signed |
1975 |
2024-01-04 15:42 |
Anonymous (not verified) |
94.188.207.229 |
Blake S. Judisch Masonry LLC |
Limited Liability Company |
510 South Fulton St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-04 |
Blake Judisch |
blakejudisch@gmail.com |
Shell rock |
Butler |
IA |
Kali Judisch |
Terri Thomsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Judisch |
blalejudisch@gmail.com |
Owner |
Shell rock |
Butler |
IA |
Kali Judisch |
Terri Thomsen |
Signed |
1974 |
2024-01-04 13:12 |
Anonymous (not verified) |
94.188.205.167 |
Cro Outdoor Services, LLC |
Limited Liability Company |
1616 NW 78TH 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. |
2023-12-20 |
Bojan Djukic |
Croodsia@gmail.com |
Clive |
Iowa |
United States |
Cezar Villalobos |
Maria Villalobos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evetee Villalobos |
e.villalobos91@gmail.com |
s/o |
Clive |
IA |
United States |
Maria Villalobos |
Cezar Villalobos |
Signed |
1973 |
2024-01-02 17:05 |
Anonymous (not verified) |
94.188.207.227 |
Diego Puente |
Proprietorship |
1420 north st, apt#3 Perry 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. |
2024-01-02 |
Diego Puente Martinez |
diegopuente0655@gmail.com |
Perry |
Dallas |
Iowa |
Jason Van Dyke |
Ashley Heffernen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Van Dyke |
jvandyke@thermalshop.com |
worker |
Cedar Rapids |
Iowa |
United States |
Jason Van Dyke |
Ashley Heffernen |
Signed |