2032 |
2024-02-07 11:05 |
Anonymous (not verified) |
94.188.207.229 |
NEIL MARTENS |
Proprietorship |
527 3RD STREET, SOUTH, ALBERT CITY, IA 50510 |
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. |
2024-02-07 |
NEIL THIESSEN MARTENS |
pkmmartens@hotmail.com |
ALBERT CITY |
BUENA VISTA |
IOWA |
JOHN CLARENCE OLERICH |
ROBERT EUGENE BELT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NEIL MARTENS |
pkmmartens@hotmail.com |
SELF |
ALBERT CITY |
BUENA VISTA |
IOWA |
JOHN CLARENCE OLERICH |
ROBERT EUGENE BELT |
Signed |
2055 |
2024-02-23 14:54 |
Anonymous (not verified) |
94.188.207.224 |
Neil Vonnahme |
Proprietorship |
13628 220th St., Arcadia, Iowa, 51430 |
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. |
2024-02-20 |
Neil Vonnahme |
neilvonnahme@gmail.com |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Vonnahme |
neilvonnahme@gmail.com |
Self |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
2059 |
2024-02-27 11:44 |
Anonymous (not verified) |
94.188.205.169 |
Dowdey Construction LLC |
Limited Liability Company |
1010 19th Ave - Rock Valley, IA 51247 |
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. |
2024-02-27 |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Self |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
218 |
2020-07-27 19:24 |
Anonymous (not verified) |
174.217.10.15 |
Bella Exteriors LLC |
Limited Liability Company |
2908 Elm St, West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-27 |
Nicholas Andersen |
nick@rightroofing.com |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Andersen |
nickande3564@gmail.com |
Self |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
748 |
2021-11-15 13:01 |
Anonymous (not verified) |
174.243.83.168 |
NC contracting |
Limited Liability Company |
2212 Oakwood Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-15 |
Nicholas Cheney |
444nicholas@gmail.com |
Ames |
Iowa |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Cheney |
444nicholas@gmail.com |
Self |
Ames |
Story |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
1790 |
2023-08-08 14:32 |
Anonymous (not verified) |
94.188.205.166 |
NJ CONSTRUCTION LLC |
Limited Liability Company |
4291 30TH AVE PETERSON, IA 51047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-08 |
NICHOLAS JAMES JONES |
njconstruction2014@hotmail.com |
PETERSON |
BUENA VISTA |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NICHOLAS JAMES JONES |
njconstruction2014@hotmail.com |
SELF |
PETERSON |
BUENA VISTA |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2167 |
2024-04-21 22:01 |
Anonymous (not verified) |
94.188.205.177 |
The Duerson Corportaion |
Proprietorship |
601 1st Ave N, 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. |
2024-04-21 |
Nicholas John Myers |
myersnicholasj@gmail.com |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas John Myers |
myersnicholasj@gmail.com |
Owner |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
1401 |
2022-12-23 09:07 |
Anonymous (not verified) |
75.162.43.221 |
Capital Express |
Limited Liability Company |
Council is Chris Blunk out of omaha NB. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-09-09 |
Nicholas Michelfelder |
nicmichelfelder@gmail.com |
8018 Valdez Circle |
polk |
iowa |
Ted Michelfelder |
lucy Sanderson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Chris Blunk |
cblunk@harrislawomaha.com |
None |
1400 SE gateway Dr. 105 |
Polk |
IA |
Theodore Michelfelder |
Rick Isacson |
Signed |
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 |
165 |
2020-05-26 14:12 |
Anonymous (not verified) |
216.51.228.161 |
Arbor Way All About Trees |
Limited Liability Company |
417 Howard 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-26 |
Nicholas Plumski |
arborway14@gmail.com |
Saint Anthony |
Marshall |
Iowa |
Michael Richards |
Nicole Plumski |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Plumski |
arborway14@gmail.com |
Owner |
St. Anthony |
Marshall |
IA |
Michael Richards |
Nicole Plumski |
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 |
1957 |
2023-12-14 18:34 |
Anonymous (not verified) |
94.188.205.166 |
Renewal by Andersen |
Limited Liability Company |
5909 OMAHA AVE N STILLWATER, MN, 55082 |
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. |
2023-12-14 |
Nicholas T Campbell |
hgchomes@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Kaut |
michael@rbadesmoines.com |
Employee |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
1962 |
2023-12-17 18:48 |
Anonymous (not verified) |
94.188.207.223 |
HGC Homes LLC |
Limited Liability Company |
6795 NE Rising Sun Dr Pleasant Hill, IA 50327 |
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. |
2023-12-17 |
Nicholas T Campbell |
hgchomes@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Kaut |
michael@rbadesmoines.com |
None |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
1059 |
2022-04-19 15:06 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILL GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
NICK HEATH |
dogboy3485@yahoo.com |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
523 |
2021-05-17 21:46 |
Anonymous (not verified) |
173.29.90.123 |
Nick keppy |
Proprietorship |
2103 e Lombard st. Davenport iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-17 |
Nick keppy |
keppylawncare@gmail.com |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca Hein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick keppy |
keppylawncare@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca hein |
Signed |
783 |
2021-12-08 10:25 |
Anonymous (not verified) |
173.31.148.43 |
Nick Larsen |
Proprietorship |
1305 7th 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. |
2021-12-08 |
Nick Larsen |
larsennick77@gmail.com |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Larsen |
joel@walkerinsuranceia.com |
Self |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
717 |
2021-11-05 13:32 |
Anonymous (not verified) |
209.252.172.87 |
Nick Wiles CW Flooring LLC |
Limited Liability Company |
Po Box 445, 710 6th St 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. |
2020-06-24 |
Nick Wiles CW Flooring LLC |
nickwiles007@gmail.com |
Wellman |
Washington |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Wiles CW Flooring LLC |
nickwiles007@gmail.com |
Self Employed |
Wellman |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1157 |
2022-06-16 07:56 |
Anonymous (not verified) |
97.125.185.191 |
Apex Remodeling |
Proprietorship |
709 w. North St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-15 |
Nick Winters |
nick.winters@apex-roofing.com |
WINTERSET |
Iowa |
Iowa |
Erin Winters |
Rob Tennat |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Winters |
nick.winters@apex-roofing.com |
Owner |
WINTERSET |
Iowa |
Iowa |
Erin Winters |
Rob Tennat |
Signed |
1301 |
2022-09-08 08:02 |
Anonymous (not verified) |
173.23.251.188 |
Nickolas Andersen |
Proprietorship |
302 E Guthrie St Linden, IA 50146 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-08 |
Nickolas Duane Andersen |
nickandersen8888@gmail.com |
Linden |
Dallas |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nickolas Andersen |
nickandersen8888@gmail.com |
self |
Linden |
Dallas |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
1574 |
2023-04-14 13:57 |
Anonymous (not verified) |
94.188.205.166 |
Nickolas Giebelstein |
Proprietorship |
1942 DIXWELL ST DAVENPORT IOWA 52802 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-14 |
Nickolas Giebelstein |
nickolasgiebelstein@gmail.com |
Davenport |
Scott |
Iowa |
Jeremy Francois |
Shane Nicholson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nickolas Giebelstein |
nickolasgiebelstein@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Jeremy Francois |
Shane Nicholson |
Signed |
28 |
2020-01-06 13:39 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
GREELEY |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
OWNER |
GREELEY |
DELAWARE |
IA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
1554 |
2023-04-04 16:30 |
Anonymous (not verified) |
94.188.205.176 |
House of Bean Studios |
Limited Liability Company |
2066 170th Street, Guthrie Center, IA 50115 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-04 |
Nicole Jazzmin Bean |
nicolebean.studios@gmail.com |
Guthrie Center |
Guthrie |
Iowa |
Daniel Bean |
Anthony Durst |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Jazzmin Bean |
houseofbeanstudios@gmail.com |
Self (Sole-proprietor LLC) |
Guthrie Center |
Guthrie |
Iowa |
Daniel Bean |
Anthony Durst |
Signed |
1291 |
2022-09-02 13:24 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
Limited Liability Company |
1107 Pheasant Valley St, Iowa City, IA 52246 |
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. |
2020-09-02 |
Nicole Keck |
niccikeckllc@gmail.com |
Iowa City |
Iowa |
United States |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
1551 |
2023-03-31 13:37 |
Anonymous (not verified) |
94.188.205.176 |
Nadarevic Group LLC |
Limited Liability Company |
3633 NW 177th Ct, Clive, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-31 |
Nicole Nadarevic |
niki@silverstonedevgroup.com |
Clive |
Dallas |
Iowa |
Jeremy Boysen |
Brooke Boysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ajdin Nadarevic |
ajdin@silverstonedevgroup.com |
Owner |
Clive |
Dallas |
Iowa |
Jeremy Boysen |
Brooke Boysen |
Signed |
1279 |
2022-08-22 13:17 |
Anonymous (not verified) |
50.83.54.168 |
Essex Family Construction |
Limited Liability Company |
290 Monmouth St SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Niki Essex |
essexfamilycontruction@outlook.com |
Cedar Rapids |
IA |
IA |
Josh Lasond |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niki Essex |
essexfamilycontruction@outlook.com |
same |
Cedar Rapids |
Iowa |
Iowa |
Josh Lasond |
Jordan Nisiewicz |
Signed |
410 |
2021-02-19 09:23 |
Anonymous (not verified) |
166.181.84.153 |
Nikolai Charikov |
Proprietorship |
115 6th St NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-19 |
Nikolai Andre Charikov |
nikolaicharikov@gmail.com |
Mitchellville |
Polk |
Iowa |
Tyler Charikov |
Mile Hufford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nikolai Charikov |
nikolaicharikov@gmail.com |
Self |
Mitchellville |
Polk |
Iowa |
Tyler Charikov |
Mile Hufford |
Signed |
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 |
1857 |
2023-10-02 16:33 |
Anonymous (not verified) |
94.188.205.169 |
Noah Blount |
Proprietorship |
2611 capitol ave, Des Moines, IA 50317, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-02 |
Noah Blount |
nbeav5@gmail.com |
Des Moines |
Des Moines |
Iowa |
Jordan Loyd |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Jackson |
Missouri |
Jordan Loyd |
Charles Woods |
Signed |
1122 |
2022-05-21 12:19 |
Anonymous (not verified) |
173.24.108.210 |
Daly Building Service,LLc |
Limited Liability Company |
409 Dammann dr. Eldridge IA, 52748 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-21 |
Noah Daly |
Noahdalyubs@gmail.com |
Eldridge |
Scott County |
Iowa |
Holly Roberts |
Corinna Daly |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derick Perry |
biglakellc@outlook.com |
Liability policy agent |
Eldridge |
Scott county |
Iowa |
Holly roberts |
Corinna Daly |
Signed |
2052 |
2024-02-22 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Noahs Ark Flooring |
Proprietorship |
6212 se 2nd st des moines iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-22 |
Noah James Daggett |
daggettnoah365@gmail.com |
Des moines |
Polk |
United States |
Malichi Cerrato |
Austin tolson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noah James Daggett |
daggettnoah365@gmail.com |
Self |
Des moines |
IA |
United States |
Malichi Cerrato |
Austin tolson |
Signed |
1123 |
2022-05-22 14:32 |
Anonymous (not verified) |
173.24.108.210 |
Daly Building Service, LLC |
Limited Liability Company |
409 Dammann Dr. Eldridge IA. 52748 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-22 |
Noah Taylor Daly |
Noahdalyubs@Gmail.com |
Eldridge |
Scott County |
Iowa |
Corinna Daly |
Holly Roberts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noah Taylor Daly |
Noahdalyubs@Gmail.com |
Owner |
Eldridge |
Scott County |
Iowa |
Corinna Daly |
Holly Roberts |
Signed |
1196 |
2022-07-11 08:13 |
Anonymous (not verified) |
166.181.85.207 |
KG Land works |
Proprietorship |
P.O. Box 931 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-12 |
Noah Wassom |
nowhwassom@yahoo.com |
Barnsdall |
Osage |
OKLAHOMA |
Dalton Gardner |
Jacob Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colten Kelley |
KGlandworks@gmail.com |
Boss |
Barnsdall |
Osage |
OKLAHOMA |
Keiven Slone |
Whyatt Slone |
Signed |
705 |
2021-11-02 11:41 |
Anonymous (not verified) |
173.23.180.159 |
Simri Enterprise LLC |
Limited Liability Company |
614 Ricker St Waterloo, IA 50703 |
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. |
2021-11-02 |
Noemi Del Carmen Trinidad |
simdelenterprisellc@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Simri Y Aldana |
simdelenterprisellc@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares |
Signed |
707 |
2021-11-03 15:30 |
Anonymous (not verified) |
173.23.180.159 |
Simdel Enterprise LLC |
Limited Liability Company |
614 Ricker St Waterloo, IA 50703 |
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. |
2021-11-03 |
Noemi Del Carmen Trinidad |
simdelenterprisellc@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares Axume |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Simri Y Aldana |
simdelenterprisellc@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares Axume |
Signed |
222 |
2020-08-03 16:16 |
Anonymous (not verified) |
204.98.109.114 |
Norval Craig Michael |
Proprietorship |
640 NE 47th Place, Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-20 |
Norval Craig Michael |
accounts@dickersonmechanical.com |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nornal Craig Michael |
accounts@dickersonmechanical.com |
Self Employeed - Sole Proprietor |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
693 |
2021-10-26 15:03 |
Anonymous (not verified) |
65.144.174.26 |
Diamante Tile |
Proprietorship |
1403 Aspen Dr Adel, IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-26 |
Octavio Bermudez |
aerosobo@gmail.com |
Des Moines |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Octavio Bermudez |
aerosobo@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
515 |
2021-05-11 15:18 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
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 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
516 |
2021-05-12 12:41 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
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 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
1388 |
2022-12-10 22:42 |
Anonymous (not verified) |
98.156.163.144 |
Springfield Staffing Solution |
Limited Liability Company |
14918 Tuff Rd, Manor TX 78653 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-10 |
Oluchukwu Nwokoye |
oly@springfieldstaffing.com |
Manor |
Travis |
United States |
Beluchukwu R Ebede |
Oluchukwu Nwokoye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beluchukwu Ebede |
admin@springfield-staffing.com |
Partner |
Manor |
Travis |
United States |
Beluchukwu R Ebede |
Oluchukwu Nwokoye |
Signed |
2069 |
2024-03-01 09:55 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd 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. |
2024-03-01 |
Orlando Manuel Nunez Mejia |
orlando20025@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2068 |
2024-03-01 09:53 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd 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. |
2024-03-01 |
Orlando Nunez |
nunezstone@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
1287 |
2022-08-30 13:11 |
Anonymous (not verified) |
173.18.22.217 |
Gomez Painting |
Limited Liability Company |
3609 56th St Des Moines IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-30 |
Orlyn Gomez |
orlyngomez9@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Orlyn Gomez |
orlyngomez9@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
73 |
2020-02-21 13:44 |
Anonymous (not verified) |
192.30.185.233 |
Viejos Masnry construction LLC |
Limited Liability Company |
1708 Villa Ave. Sioux City IA 51103 |
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. |
2020-02-13 |
Oscar Castro Ramirez |
veijosconstruction@gmail.com |
Sioux City |
Woodbury |
Iowa |
JEFFREY H MCCLINTOCK |
Nancy Fleming |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Viejos Masonry Construction LLC |
veijosconstruction@gmail.com |
Owner/President |
SIOUX CITY |
Woodbury |
Iowa |
Nancy Fleming |
Jeffrey Hugh McClintock |
Signed |
762 |
2021-11-22 09:23 |
Anonymous (not verified) |
71.34.169.117 |
Oscar Lopez |
Proprietorship |
1175 Office Park Road Apt 109 West Des Moines, Iowa 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-15 |
Oscar Lopez |
deb@piciowa.com |
WDM |
Polk |
ia |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Oscar Lopez |
deb@piciowa.com |
self |
WDM |
Polk |
IA |
Debra Stratton |
Kelly Denger |
Signed |
2098 |
2024-03-15 18:38 |
Anonymous (not verified) |
94.188.205.177 |
OMG Bros, LLC |
Limited Liability Partnership |
404 Ivanhoe Rd, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-15 |
Oscar Omar Gaytan |
og210666@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Jake Usher |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tristan Anthony Siebrands |
omgservices@omgbros.org |
Partner |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Jake Usher |
Signed |
2090 |
2024-03-12 14:16 |
Anonymous (not verified) |
94.188.205.169 |
Oscar Sosa |
Proprietorship |
110 E Cherry 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. |
2023-01-01 |
Oscar Sosa |
oscarsosa@live.com |
Cherokee |
Cherokee |
Iowa |
Adrian Dominguez |
Ronald Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Halverson |
ron@sppinsurance.com |
independent contractor |
Cherokee |
Cherokee |
IA |
Oscar Sosa |
Ronald Halverson |
Signed |
641 |
2021-09-17 09:16 |
Anonymous (not verified) |
72.255.121.118 |
Osman Gonzalez-Sarceno |
Proprietorship |
1403 Aspen Dr Adel, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-17 |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
IA |
Melissa Bolanos |
Brianna Fuller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Owner |
Des Moines |
Polk |
Iowa |
Melissa Bolanos |
Brianna Fuller |
Signed |
1420 |
2023-01-12 13:42 |
Anonymous (not verified) |
75.162.144.157 |
Clearer Sky |
Limited Liability Company |
2305 Drake Park Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-12 |
Osvaldo Mayorga Delgado |
grae1524@gmail.com |
Des Moines |
Polk |
Iowa |
Juan Manuel Mayorga Delgado |
Gloria Lorena Enamorado Guzman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Osvaldo Mayorga Delgado |
Grae1524@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Juan Manuel Mayorga Delgado |
Gloria Lorena Enamorado Guzman |
Signed |
293 |
2020-10-28 06:58 |
Anonymous (not verified) |
173.189.165.102 |
Boettcher Construction |
Proprietorship |
PO Box 482, 843 West Business 30 |
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. |
2020-10-28 |
otto p boettcher |
obc32@live.com |
Lisbon |
IA |
iowa |
Barb Boettcher |
Barb Boettcher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
otto p boettcher |
obc32@live.com |
same person |
Lisbon |
IA |
iowa |
Barb Boettcher |
Barb Boettcher |
Signed |
190 |
2020-06-19 11:08 |
Anonymous (not verified) |
107.77.207.128 |
PAT Construction |
Limited Liability Company |
6007 Sw 15th 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. |
2020-06-21 |
Pablo Aguilar Tolentino |
PATConstruction77@gmail.com |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pablo Aguilar Tolentino |
PATconstruction77@gamil.com |
owner |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
Signed |