483 |
2021-04-16 10:47 |
Anonymous (not verified) |
204.155.61.217 |
Joseph Jones DBA Jones Sealcoating and Asphalt Repair |
Limited Liability Company |
1033 Hummingbird 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. |
2021-04-16 |
Joseph Jones |
iscrapcu@yahoo.com |
Waterloo |
Iowa |
Iowa |
Kyle Hildman |
Dan Sinnott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jospeh Jones |
iscrapcu@yahoo.com |
OWNER |
Waterloo |
Black Hawk |
IA |
Kyle Hildman |
Dan Sinnott |
Signed |
484 |
2021-04-16 10:58 |
Anonymous (not verified) |
66.188.136.150 |
Erick Hodges |
Proprietorship |
3039 Magnolia Dr. Bettendorf, IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-16 |
Erick Hodges |
kschumacher@tricorinsurance.com |
Bettendorf |
Scott |
IA |
Jordan Bass |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erick Hodges |
kschumacher@tricorinsurance.com |
Same |
Bettendorf |
Scott |
IA |
Jordan Bass |
Russell Masartis |
Signed |
485 |
2021-04-16 11:58 |
Anonymous (not verified) |
69.57.23.123 |
CRAIG AUKES |
Proprietorship |
43397 50TH AVENUE, BUFFALO CENTER, IA 50424 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-16 |
CRAIG AUKES |
cdaukes@yahoo.com |
Buffalo Center |
Winnebago |
Iowa |
Steven Heyer |
Cindy Mawdsley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CRAIG AUKES |
cdaukes@yahoo.com |
Employer-Proprietor |
Buffalo Center |
Winnebago |
IA |
Steven Heyer |
Cindy Mawdsley |
Signed |
486 |
2021-04-19 15:09 |
Anonymous (not verified) |
65.103.82.36 |
Westeros Property Maintenance, LLC |
Limited Liability Company |
2004 Leclaire ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-01 |
Theodore Brown |
westerospropertymaintenance@outlook.com |
Davenport |
Scott |
IA |
Jordan |
Kayla |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Theodore Brown |
westerospropertymaintenance@outlook.com |
Owner |
Davenport |
Scott |
IA |
Jordan |
Kayla |
Signed |
491 |
2021-04-20 15:57 |
Anonymous (not verified) |
199.102.210.217 |
mjm,inc |
Proprietorship |
32345 200th st dallas centert ia 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-20 |
john paul wewrner |
johnpwerner17@gmail.com |
osage |
michell |
ia |
carolyn lee werner |
amanda lee johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
johnwerner |
johnpwerner17@gmail.com |
friend |
osage |
mithell |
ia |
carolyn lee werner |
amanda lee johnson |
Signed |
492 |
2021-04-22 08:33 |
Anonymous (not verified) |
66.188.136.150 |
Adrian Hackney |
Proprietorship |
1513 7th St. Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-20 |
Adrian Hackney |
kschumacher@tricorinsurance.com |
Boone |
Boone |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Hackney |
kschumacher@tricorinsurance.com |
Same |
Boone |
Boone |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
493 |
2021-04-22 08:54 |
Anonymous (not verified) |
66.188.136.150 |
Frank Lantz |
Proprietorship |
609 Clinton Street, Charles City, IA 50616 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-21 |
Frank Lentz |
kschumacher@tricorinsurance.com |
Charles City |
Floyd |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frank Lantz |
kschumacher@tricorinsurance.com |
Same |
Charles City |
Floyd |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
495 |
2021-04-23 11:26 |
Anonymous (not verified) |
98.22.221.1 |
T & S Industries Inc |
Partnership |
200 West Jefferson |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-23 |
Tim Hunter |
tands@iowatelecom.net |
Afton |
IA |
IA |
Cindy R Harper |
Richard Mordock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travelers Insurance |
lisa@allplansins.com |
agent |
Afton |
IA |
IA |
Cindy R Harper |
Richard Mordock |
Signed |
498 |
2021-04-27 12:54 |
Anonymous (not verified) |
173.31.147.225 |
TYREL KINKADE DBA: KINKADE CONSTRUCTION |
Proprietorship |
2289 165TH ST UNIT 10D |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-21 |
TYREL KINKADE |
hogtyd97@yahoo.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL KINKADE |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
501 |
2021-04-29 15:47 |
Anonymous (not verified) |
184.179.6.93 |
Rodney Bohannon |
Proprietorship |
5221 Crogans Way Rd, Council Bluffs IA 51501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-29 |
Rodney Bohannon |
bohannonrod@gmail.com |
Council Bluffs |
POTTAWATTAMIE |
iowa |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodney Bohannon |
bohannonrod@gmail.com |
Owner |
Council Bluffs |
POTTAWATTAMIE |
IA |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
503 |
2021-05-05 11:27 |
Anonymous (not verified) |
50.82.130.211 |
Davonius Reed |
Limited Liability Company |
1913 Upton Avenue, Waterloo IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-01 |
Davonius Reed |
cmins_re@mchsi.com |
Waterloo |
Black Hawk |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Davonius Reed |
cmins_re@mchsi.com |
Self |
Waterloo |
Black Hawk |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
517 |
2021-05-12 15:08 |
Anonymous (not verified) |
66.188.136.150 |
Lawrence D Todd Jr. |
Proprietorship |
540 Sullivan St. Dubuque, IA 52001 |
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. |
2021-05-05 |
Lawrence D Todd Jr. |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lawrence D Todd Jr. |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Shuree Behr |
Jordan Bass |
Signed |
521 |
2021-05-17 14:23 |
Anonymous (not verified) |
66.188.136.150 |
Ron Wagner |
Proprietorship |
602 1/2 Ave G Apt. 5 Ft. Madison, IA 52627 |
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 |
Ron Wagner |
kschumacher@tricorinsurance.com |
Ft. Madison |
Lee |
IA |
Jordan Bass |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Wagner |
kschumacher@tricorinsurance.com |
Same |
Ft. Madison |
Lee |
IA |
Jordan Bass |
Shuree Behr |
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 |
527 |
2021-05-20 07:54 |
Anonymous (not verified) |
66.43.242.142 |
mcconnells custom construction |
Proprietorship |
1074 240th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
John McConnell |
jnkatmcc@netins.net |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
McConnell's Custom Construction |
jnkatmcc@netins.net |
owner |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
533 |
2021-06-03 20:37 |
Anonymous (not verified) |
75.162.171.128 |
KP Repair LLC |
Limited Liability Company |
719 10th St. NE Mason City, Iowa. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-03 |
Alexander Wessels |
kprepair@outlook.com |
MASON CITY |
Cerro Gordo |
IA |
Sadie Lonning |
Dusty Howe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alexander Wessels |
kprepair@outlook.com |
Owner |
MASON CITY |
Cerro Gordo |
IA |
Sadie Lonning |
Dusty Howe |
Signed |
539 |
2021-06-08 17:06 |
Anonymous (not verified) |
66.188.136.150 |
Todd Sechler |
Proprietorship |
505 5th Street Wellman, IA 52356 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-08 |
Todd Sechler |
kschumacher@tricorinsurance.com |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Sechler |
kschumacher@tricorinsurance.com |
Same |
Wellman |
Washington |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
543 |
2021-06-16 12:49 |
Anonymous (not verified) |
174.250.64.145 |
McCulloch Construction LLC |
Limited Liability Company |
2590 SE 68TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-01 |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
Owner |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
560 |
2021-07-08 08:46 |
Anonymous (not verified) |
66.188.136.150 |
Darius Harvey |
Proprietorship |
2738 E 53rd. Apt. 7 Davenport, IA 52807 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-07 |
Darius Harvey |
kschumacher@tricorinsurance.com |
Davenport |
Scott |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darius Harvey |
kschumacher@tricorinsurance.com |
Same |
Davenport |
Scott |
IA |
Mitch Kemp |
Shuree Behr |
Signed |
564 |
2021-07-08 13:33 |
Anonymous (not verified) |
173.31.156.49 |
SS Docks |
Limited Liability Company |
P.O. Box 561 Okoboji IA 51355-0561 |
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. |
2021-07-08 |
Jason Andrew Snow |
snowjas75@gmail.com |
Lake Park |
Dickinson |
IA |
Amber Egesdal |
Vickie Walters |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
SS Docks |
snowjas75@gmail.com |
Owner |
Okoboji |
Dickinson |
IA |
Amber Egesdal |
Vickie Walters |
Signed |
576 |
2021-07-14 18:13 |
Anonymous (not verified) |
69.169.10.40 |
J&M Excavation Inc. |
Limited Liability Company |
411 Pine Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-14 |
Bruce Bilyeu |
jmexcavation@outlook.com |
Norwalk |
Warren |
IA |
Mike Petersen |
Dennis Bilyeu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Bilyeu |
jmexcavation@outlook.com |
Owner |
Norwalk |
Warren |
IA |
Mike Petersen |
Dennis Bilyeu |
Signed |
582 |
2021-07-22 15:14 |
Anonymous (not verified) |
173.24.111.218 |
Joseph Davis |
Proprietorship |
7257 Valley Dr, bettendorf ia 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Joseph Davis |
jtigerd@live.com |
Bettendorf |
Scott |
IA |
Jacob nagel |
Nick brewer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Davis |
jtigerd@live.com |
Agent |
Bettendorf |
IA |
IA |
Jacob nagel |
Nick brewer |
Signed |
587 |
2021-07-26 12:40 |
Anonymous (not verified) |
172.56.7.208 |
Central Iowa Dict Cleaning |
Proprietorship |
1414 Adventureland Dr #4206 Altoona IA 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-26 |
Gary Gallagher |
ductclean@gmail.com |
Altoona |
Polk |
IA |
Meghan Militti |
Todd Nastase |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Gallagher |
ductclean@gmail.com |
Self |
Altoona |
Polk |
IA |
Meghan Militti |
Todd Nastase |
Signed |
596 |
2021-08-04 10:48 |
Anonymous (not verified) |
184.80.177.137 |
Down Home Decor Inc |
Proprietorship |
1021 2nd Ave SE Ste 200 Dyersville, IA 52040 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-04 |
Steve Knipper |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
601 |
2021-08-12 16:37 |
Anonymous (not verified) |
172.58.83.7 |
C & G Construction LLC |
Limited Liability Company |
659 Sw Springfield Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-12 |
Griselda Corona |
candgconst@gmail.com |
Ankeny |
Polk |
IA |
Clifton Kinney |
Marisol Chavira |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Carlos corona |
candgconst@gmail.com |
Partner |
Ankeny |
Polk |
IA |
Clifton Kinney |
Marisol Chavira |
Signed |
608 |
2021-08-17 21:35 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
James D VanderBeek |
jvanderbeek@plbci.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
Zackery James VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Zackery J VanderBeek |
Signed |
609 |
2021-08-17 21:42 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
Zackery James VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
James. VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Barbara M VanderBeek |
Signed |
613 |
2021-08-19 21:54 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, Iowa 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Zackery J VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
614 |
2021-08-20 12:20 |
Anonymous (not verified) |
172.58.235.242 |
Darren Qualls |
Proprietorship |
1515 Dewitt St. Ellsworth. IA 50075 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Darren Wade Qualls |
d.qualls@outlook.com |
Ellsworth |
Hamilton |
IA |
Jeannie Kathleen Qualls |
Andrea Littleton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darren Wade Qualls |
d.qualls@outlook.com |
Self/Proprietor |
Ellsworth |
IA |
IA |
Jeannie Kathleen Qualls |
Andrea Littleton |
Signed |
616 |
2021-08-23 13:14 |
Anonymous (not verified) |
173.25.153.19 |
Levon |
Proprietorship |
210 S 41st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-23 |
Levon shheba |
sheebalevon@gmail.com |
West des Moines IA 50265 |
Polk county |
IA |
Alina sheeba |
Delon sheeba |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levon sheeba |
sheebalevon@gmail.com |
Myself |
West des Moines IA 50265 |
Polk county |
IA |
Alina sheeba |
Delon sheeba |
Signed |
618 |
2021-08-23 15:17 |
Anonymous (not verified) |
173.17.131.91 |
Leaffilter North of Iowa, LLC |
Proprietorship |
5650 NW 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. |
2021-08-23 |
Jorge Meraz |
jmaraz961@gmail.com |
2906 e madison avenue |
Des moines |
IA |
Jisel chaves |
Melvin arevalo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jorge meraz |
jmeraz961@gmail.com |
Self |
Des moines |
Des moine |
IA |
Jusel chavez |
Melvin arevalo |
Signed |
619 |
2021-08-25 14:31 |
Anonymous (not verified) |
192.154.15.2 |
MAV Restorations LLC |
Limited Liability Company |
5461 Meadow Ct, Asbury, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-25 |
Matthew Vaske |
mlvaske@gmail.com |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Vaske |
mlvaske@gmail.com |
Self |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
620 |
2021-08-26 16:26 |
Anonymous (not verified) |
75.162.146.246 |
Daniel Meza Reyes |
Proprietorship |
1640 E Army Post RD Des Moines IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-23 |
Daniel Meza Reyes |
danielmr9247@gmail.com |
Des Moines |
polk |
IA |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Meza Reyes |
danielmr9247@gmail.com |
self |
Des Moines |
polk |
IA |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
627 |
2021-08-31 16:12 |
Anonymous (not verified) |
173.18.16.129 |
D's Home Improvement |
Limited Liability Company |
665 27th St Des Moines IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-31 |
Dustin Mitchell |
dustinmitchell8855@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Mitchell |
dustinmitchell8855@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
661 |
2021-10-01 09:00 |
Anonymous (not verified) |
71.34.184.201 |
Jose Tavares |
Proprietorship |
1175 Office Park Rd Apt 109 WDM 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. |
2021-09-24 |
Jose Tavares |
deb@piciowa.com |
1175 Office Park Rd Apt 109 WDM IA 50266 |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Tavares |
deb@piciowa.com |
self |
WDM |
Polk |
IA |
Martin Pinon |
Debra Stratton |
Signed |
666 |
2021-10-07 08:12 |
Anonymous (not verified) |
208.126.166.149 |
Toribio Construction LLC |
Limited Liability Company |
107 W Maxson Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-07 |
Jose Toribio |
osorioabigail0224@gmail.com |
West Liberty |
Muscatine |
IA |
Anthony Johnson |
Abigail Osorio |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Toribio |
osorioabigail0224@gmail.com |
Owner |
West Liberty |
Muscatine |
IA |
Anthony Johnson |
Abigail Osorio |
Signed |
668 |
2021-10-12 16:11 |
Anonymous (not verified) |
173.18.22.217 |
Mo's Cleaning LLC |
Limited Liability Company |
1412 E 23rd St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-12 |
Melissa Jones |
commcleanwithme123@gmail.com |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Jones |
commcleanwithme123@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
672 |
2021-10-13 16:05 |
Anonymous (not verified) |
75.162.218.218 |
Arturos Interiors LLC |
Limited Liability Company |
3305 se 22nd apt 15 Des Moines IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-29 |
Arturo mejia |
arturomcruz20@hotmail.com |
Des Moines |
polk |
IA |
yolanda mendoza |
liliana sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arturo Mejia |
arturomcruz20@hotmail.com |
member |
Des Moines |
polk |
IA |
Yolanda Mendoza |
lialiana sanchez |
Signed |
675 |
2021-10-15 11:22 |
Anonymous (not verified) |
75.162.156.37 |
MCG FLOORING, LLC |
Limited Liability Company |
2115 CARPENTER AVE DES MOINES IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-15 |
GABRIELA GOMEZ |
MCGFLOORINGLLC@GMAIL.COM |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MCG FLOORING, LLC |
MCGFLOORINGLLC@GMAIL.CON |
OWNER |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
676 |
2021-10-15 11:29 |
Anonymous (not verified) |
75.162.156.37 |
MCG FLOORING, LLC |
Limited Liability Company |
2115 CARPENTER AVE DES MOINES, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-10-15 |
MANUEL CONTRERAS BERNAL |
MCGFLOORINGLLC@GMAIL.COM |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
MCG FLOORING, LLC |
MCGFLOORINGLLC@GMAIL.CON |
OWNER |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
679 |
2021-10-18 13:14 |
Anonymous (not verified) |
173.18.22.217 |
Xscape Extreme Hard & Landscape |
Proprietorship |
3215 E 25th CT Bldg Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-18 |
Mike Tapper |
Tapper4981@gmail.com |
Des Moines |
Polk |
IA |
Lesa Dillon |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Tapp |
Tapper4981@gmail.com |
Owner |
Des Moines |
Des Moines |
IA |
Lesa Dillon |
Kelly Coluzzi |
Signed |
692 |
2021-10-26 14:58 |
Anonymous (not verified) |
65.144.174.26 |
Jake Kenney |
Proprietorship |
3201 Hillsdale 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. |
2021-10-26 |
Jacob Daniel Kenney |
Jakedkenney@hotmail.com |
Urbandale |
Polk |
Iowa |
Abbey Kenney |
Jory Ringler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Daniel Kenney |
jakedkenney@hotmail.com |
Owner |
Urbandale |
polk |
ia |
abbey kenney |
jory ringler |
Signed |
711 |
2021-11-04 13:07 |
Anonymous (not verified) |
174.216.69.18 |
Corey Gramowski |
Proprietorship |
2101 21st ST Emmetsburg IA 50536 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-04 |
Corey Gramowski |
gramowski@windstream.net |
Emmetsburg |
Palo Alto |
IA |
Frank Kliegl |
John Heddinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Gramowski |
gramowski@windstream.net |
Self |
Emmetsburg |
Palo Alto |
IA |
Frank Kliegl |
John Heddinger |
Signed |
725 |
2021-11-05 14:32 |
Anonymous (not verified) |
174.198.66.202 |
Jay Schulte |
Proprietorship |
7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 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. |
2020-09-15 |
Jay Schulte |
schultejay@Hotmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Schulte |
schultejay@hotmail.com |
Self Employed |
Cedar Rapids |
Linn |
Ia |
Sarah Coberley |
Heather Howell |
Signed |
735 |
2021-11-11 14:10 |
Anonymous (not verified) |
72.13.16.172 |
T MILLER TRUCKING LLC |
Limited Liability Company |
1682 MONROE 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. |
2019-11-18 |
T MILLER TRUCKING LLC |
DAVE@ALLSEASONSTRUCKING.COM |
WATERVILLE |
ALLAMAKEE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
T MILLER TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
WATERVILLE |
ALLAMAKEE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
739 |
2021-11-11 14:46 |
Anonymous (not verified) |
72.13.16.172 |
WILLIAM THIAS |
Proprietorship |
PO BOX 152 |
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. |
2019-11-18 |
WILLIAM THIAS |
dave@allseasonstrucking.com |
CLERMONT |
FAYETTE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
WILLIAM THIAS |
dave@allseasonstrucking.com |
PRESIDENT |
CLERMONT |
FAYETTE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
740 |
2021-11-11 14:54 |
Anonymous (not verified) |
72.13.16.172 |
LECHTENBERG TRUCKING LLC |
Limited Liability Company |
10185 HWY 18 |
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. |
2019-11-18 |
LECHTENBERG TRUCKING LLC |
dave@allseasonstrucking.com |
POSTVILLE |
CLAYTON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LECHTENBERG TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
POSTVILLE |
CLAYTON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
741 |
2021-11-11 15:09 |
Anonymous (not verified) |
72.13.16.172 |
RICK VANGORDER |
Proprietorship |
2549 QUASQUETON DIAGONAL BLVD |
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. |
2019-11-18 |
RICK VANGORDER |
dave@allseasonstrucking.com |
INDEPENDENCE |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICK VANGORDER |
dave@allseasonstrucking.com |
PRESIDENT |
INDEPENDENCE |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
742 |
2021-11-11 15:14 |
Anonymous (not verified) |
72.13.16.172 |
JACOB WESLEY JOHNSON |
Proprietorship |
1306 BAXTER 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. |
2019-11-18 |
JACOB WESLEY JOHNSON |
dave@allseasonstrucking.com |
FAIRBANK |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JACOB WESLEY JOHNSON |
dave@allseasonstrucking.com |
PRESIDENT |
FAIRBANK |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
743 |
2021-11-11 15:19 |
Anonymous (not verified) |
72.13.16.172 |
ROLING TRANSPORT LLC |
Limited Liability Company |
33041 395TH 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. |
2019-11-18 |
ROLING TRUCKING LLC |
dave@allseasonstrucking.com |
BELLEVUE |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ROLING TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
BELLEVUE |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |