1089 |
2022-05-05 15:49 |
Anonymous (not verified) |
173.18.22.217 |
Dave Brecht Lawn Care |
Limited Liability Company |
5213 SE 27th St 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. |
2022-05-05 |
Dave Brecht |
Fagenmich@gmail.com |
Des Moines |
Polk |
IA |
Lesa Reeves |
Mitch Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dave Brecht |
Fagenmich@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Lesa Reeves |
Mitch Coluzzi |
Signed |
1104 |
2022-05-16 13:00 |
Anonymous (not verified) |
65.144.174.26 |
Medrano Flooring LLC |
Limited Liability Company |
8186 Harbach Blvd Apt 1, 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. |
2022-05-16 |
Joel Medrano |
medranojoel397@gmail.com |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Medrano |
medranojoel397@gmail.com |
Self |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
1115 |
2022-05-17 19:36 |
Anonymous (not verified) |
173.23.50.204 |
Delgado Electrical Services |
Limited Liability Company |
1210 Creston Ave 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. |
2022-05-17 |
Cesar Delgado |
delgado.electrical@gmail.com |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Delgado |
cesar.delgado31@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
1118 |
2022-05-18 11:12 |
Anonymous (not verified) |
174.215.249.55 |
Nilson construction |
Proprietorship |
3219 bowdoin st Des Moines Iowa 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-18 |
Romel Edenilson saravia Aparicio |
romelsaravia5@gmail.com |
Des Moines |
Polk |
Iowa |
Alvaro camacho |
Ricardo Iyan campuzano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Romel edenilson saravia aparicio |
romelsaravia5@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Alvaro camacho |
Ricardo iyan campuzano |
Signed |
1120 |
2022-05-19 09:49 |
Anonymous (not verified) |
65.125.92.130 |
JG Landscaping, LLC |
Limited Liability Company |
317 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. |
2022-05-19 |
Javier Alexander Guzman |
alexguz76@outlook.com |
Des Moines |
Polk |
IA |
Brenda Reedy |
Chad Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier Alexander Guzman |
alexguz76@outlook.com |
Self |
Des Moines |
Polk |
IA |
Brenda Reedy |
Chad Smith |
Signed |
1134 |
2022-05-31 09:08 |
Anonymous (not verified) |
65.125.92.130 |
EAC Multi-Services, Inc, |
Proprietorship |
6224 Forest 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. |
2022-05-31 |
Alan E Enamordo |
enriqueecalowcare@gmail.com |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alan E Enamordo |
enriqueecalowcare@gmail.com |
self |
Des Moines |
Polk |
IA |
Chad Smith |
Adam Smith |
Signed |
1141 |
2022-06-03 08:15 |
Anonymous (not verified) |
173.23.251.188 |
SP Exteriors, LLC |
Limited Liability Company |
804 Philip St Des Moines, IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-03 |
Travis Espey |
tespey48@gmail.com |
Des Moines |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Espey |
tespey48@gmail.com |
owner |
Des Moines |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
1150 |
2022-06-10 16:14 |
Anonymous (not verified) |
173.29.125.38 |
Vernon Tim McClain |
Limited Liability Company |
2717 Thompson ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-10 |
Vernon Tim McClain |
mcclainlawn@gmail.com |
Des Moines |
POlk |
Iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
vernon mcclain |
mcclainlawn@gmail.com |
business owner |
des moines |
polk |
iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
1154 |
2022-06-14 00:27 |
Anonymous (not verified) |
174.213.144.227 |
Arben Bahtirovic |
Partnership |
3060 South East Grimes Blvd, Suite 100-300 Grimes, Iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-06-14 |
Arben Bahtirovic |
arben2002@gmail.com |
West Des Moines |
Polk |
IOWA |
Senida bahtirovic |
Mario mandic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arben Bahtirovic |
arben2002@gmail.com |
Contractor |
West Des Moines |
Polk |
IOWA |
Senida bahtirovic |
Marijo mandic |
Signed |
1155 |
2022-06-14 12:44 |
Anonymous (not verified) |
207.45.82.36 |
GREEN AND SHINE SERVICES INC |
Proprietorship |
210 Ne 41st st Apt 203 Ankeny, IA, 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-14 |
ALEX A. LOPEZ REDONDO |
greenandshineservices@gmail.com |
ankeny |
polk |
iowa |
Giselle roa |
Marta casado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex A Lopez Redondo |
greenandshineservices@gmail.com |
propery |
ankeny |
polk |
iowa |
Giselle Roa |
Marta Casado |
Signed |
1159 |
2022-06-17 10:58 |
Anonymous (not verified) |
174.235.208.232 |
Vertex Construction Services |
Limited Liability Company |
1620 E Diehl Ave, 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. |
2022-06-17 |
William Dombrowski |
wdombrowski629@gmail.com |
Des moines |
Polk |
Iowa |
Clark Newbury |
Lisa Rodriguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Dombrowski |
wdombrowski629@gmail.com |
Owmer |
Des moines |
Polk |
Iowa |
Clark Newbury |
Lisa Rodriguez |
Signed |
1162 |
2022-06-23 08:17 |
Anonymous (not verified) |
172.58.122.231 |
John lewis |
Limited Liability Company |
2130 lay 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. |
2022-06-23 |
John trick lewis |
Johnericklewis@gmail.com |
Des moines |
polk |
iowa |
Robert Rodriguez |
Penny scroggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John lewis |
Johnericklewis@gmail.com |
co worker |
Des moines |
polk |
iowa |
Robert Rodriguez |
Penny scoggins |
Signed |
1166 |
2022-06-23 09:44 |
Anonymous (not verified) |
74.84.106.106 |
alan squires |
Proprietorship |
702 2nd ave sw #4 |
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. |
2022-06-23 |
alan squires |
shanesq411@gmail.comm |
altoona |
polk |
iowa |
TIna Owens |
Rita Littell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
alan squires |
shanesq411@gmail.com |
self |
altoona |
polk |
iowa |
Tina Owens |
Rita Littell |
Signed |
1168 |
2022-06-23 12:57 |
Anonymous (not verified) |
74.84.106.106 |
dora valadez |
Proprietorship |
1244 e 32 nd 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. |
2022-06-23 |
dora valadez |
towens@smartind.com |
Des Moines |
Polk |
Iowa |
Tina Owens |
Kim Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
dora valadez |
towens@smartind.com |
self |
Des Moines |
Polk |
Iowa |
Tina Owens |
Kim Owens |
Signed |
1169 |
2022-06-23 16:23 |
Anonymous (not verified) |
159.45.71.17 |
Whitlow Remodeling and Home Services, LLC |
Limited Liability Company |
6421 NW 54th Ct Johnston Iowa 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. |
2022-06-23 |
Scot Alan Whitlow |
resaw375@msn.com |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scot Alan Whitlow |
resaw375@msn.com |
Owner |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
1171 |
2022-06-24 09:40 |
Anonymous (not verified) |
65.125.92.130 |
Vega's Pro Painting, LLC |
Limited Liability Company |
2415 River Meadows Dr. 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. |
2022-06-24 |
Daniel Vega Camacho |
dvega50265@gmail.com |
Des Moines |
Polk |
IA |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Vega Camacho |
dvega50265@gmail.com |
Self |
Des Moines |
Polk |
IA |
Chad Smith |
Adam Smith |
Signed |
1180 |
2022-07-06 03:55 |
Anonymous (not verified) |
172.58.83.226 |
John lewis |
Limited Liability Company |
2130 lay St Des Moines 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. |
2022-07-06 |
John lewis |
johnericklewis@gmail.com |
Des Moines |
polk |
iowa |
Robert Rodriguez |
Penny scroggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay skills transport |
johnericklewis@gmail.com |
friend |
Des Moines |
polk |
iowa |
John lewis |
panny scrogging |
Signed |
1181 |
2022-07-06 10:10 |
Anonymous (not verified) |
173.18.22.217 |
MB Masonry LLC |
Limited Liability Company |
PO Box 7534 |
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. |
2022-07-06 |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Owner |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
1183 |
2022-07-06 13:43 |
Anonymous (not verified) |
50.82.95.247 |
2DL Construction, LLC |
Limited Liability Company |
1134 21st Street, 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. |
2022-07-06 |
Diego Lopez |
calihernandez01@icloud.com |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Diego Lopez |
calihernandez01@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
1193 |
2022-07-08 10:18 |
Anonymous (not verified) |
173.18.22.217 |
OWWT |
Limited Liability Company |
1915 SE Clovere Ridge Dr. Ankeny IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Robert M Jackson |
dgfl08051982@gmail.com |
Ankeny |
Polk |
IA |
Lesa Reeves |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Jackson |
dgfl08051982@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Lesa Reeves |
Erick Sculdt |
Signed |
1205 |
2022-07-14 13:29 |
Anonymous (not verified) |
173.18.22.217 |
Residence Electric LLC |
Limited Liability Company |
5465 Mills Civic Pkwy #317 West Des Moines 50266 |
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. |
2022-07-14 |
Anthony Rivera |
residenceelectric@outlook.com |
West Des Moines |
Polk |
Iowa |
Lesa Reeves |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Rivera |
residenceelectric@outlook.com |
Owner |
West Des Moines |
Polk |
Iowa |
Lesa Reeves |
Erick Schuldt |
Signed |
1206 |
2022-07-14 14:34 |
Anonymous (not verified) |
75.162.163.45 |
General construction services |
Proprietorship |
7071 30th Ave 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. |
2022-07-14 |
ned cunconan |
ned.gcs@gmail.com |
Norwalk |
polk |
IA |
Sheena Cunconan |
Sheena Cunconan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ned cunconan |
ned.gcs@gmail.com |
subcontractor |
Norwalk |
polk |
Iowa |
Sheena Cunconan |
Sheena Cunconan |
Signed |
1208 |
2022-07-15 11:06 |
Anonymous (not verified) |
173.18.22.217 |
JL Elite Painting |
Limited Liability Company |
3416 NW 20th St Ankeny IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-15 |
Lizeth Benitez |
jl.elite.painting@gmail.com |
Ankeny |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lizeth Benitez |
jl.elite.painting@gmail.com |
owner |
Ankeny |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
1228 |
2022-07-26 10:06 |
Anonymous (not verified) |
173.23.93.3 |
Gaytan Framing LLC |
Limited Liability Company |
2418 East 37th Court |
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. |
2022-07-26 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
United States |
CARLA C. GAYTAN |
Juan Franco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan |
jose1988.jg8@gmail.com |
self |
Des Moines |
IA |
United States |
CARLA C. GAYTAN |
Juan franco |
Signed |
1233 |
2022-07-28 22:53 |
Anonymous (not verified) |
166.181.84.53 |
Leaffilter |
Limited Liability Company |
3060 SE Grimes Blvd Suite 100-300, Grimes, IA 501113060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-28 |
Mohammed Albayati |
mrcarbody.81@gmail.com |
Johnston |
Polk |
Iowa |
Tammy Decker |
Waffa Albayati |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meghan Mcilhon |
mmcilhon@leaffilter.com |
Human Resources |
Grimes |
Polk |
Iowa |
Tammy Decker |
Waffa Albayati |
Signed |
1250 |
2022-08-10 09:10 |
Anonymous (not verified) |
75.162.190.54 |
Merit Paint Company |
Proprietorship |
1629 24th 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. |
2022-08-10 |
James Edward Simpson |
jaybirdsimpson40@aol.com |
Des Moines |
Polk |
Iowa |
Regan Simpson |
Hudson Simpson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Simpson |
jaybirdsimpson40@aol.com |
Owner |
Des Moines |
Polk |
Iowa |
Regan Simpson |
Hudson Simpson |
Signed |
1252 |
2022-08-12 13:11 |
Anonymous (not verified) |
166.181.85.235 |
Cesar cardenas |
Proprietorship |
48644 roma valley 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. |
2022-06-06 |
Cesar Octavio Cardenas navarrete |
cesarcardenas981@gmail.com |
Des moines |
Polk |
Iowa |
Cesar cardenas navarrete |
Cesar cardenas Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar cardenas |
cesarcardenas981@gmail.com |
Myself |
Des moines |
Polk |
Iowa |
Cesar cardenas |
Cesar cardenas gonzalez |
Signed |
1268 |
2022-08-18 15:01 |
Anonymous (not verified) |
75.162.65.221 |
Furgy's Carpet |
Limited Liability Company |
6930 NE 56th St Lot 92, 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. |
2022-08-18 |
Micheal Furgison |
furgy4f@gmail.com |
Altoona |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Micheal Furgison |
furgy4f@gmail.com |
Self |
Altoona |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1272 |
2022-08-19 09:36 |
Anonymous (not verified) |
75.162.65.221 |
William Jones |
Limited Liability Company |
1639 E 13th St Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-19 |
William Jones |
billjones1229@yahoo.com |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Jones |
billjones1229@yahoo.com |
Self |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1273 |
2022-08-19 10:40 |
Anonymous (not verified) |
75.162.65.221 |
Robert Kilgore |
Proprietorship |
2404 34th St Des Moines 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-19 |
Robert Kilgore |
robertkilgore1969@gmail.com |
Des Moines |
Polk |
Iowa |
Randy Lacine |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Kilgore |
robertkilgore1969@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1278 |
2022-08-22 12:15 |
Anonymous (not verified) |
75.162.65.221 |
Skyler Thayer |
Proprietorship |
719 34th 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. |
2022-08-22 |
Skyler Thayer |
thayerskyler@gmail.com |
West Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Skyler Thayer |
thayerskyler@gmail.com |
Self |
West Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1284 |
2022-08-26 08:07 |
Anonymous (not verified) |
97.125.43.203 |
Sindi Merida-Alvarez dba MA Construciton LLC |
Limited Liability Company |
2048 Lyon St Des Moines, Iowa 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. |
2022-08-22 |
Sindi Merida-ALvarez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sindi Merida- ALvarez |
deb@piciowa.com |
selk |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
1285 |
2022-08-26 08:22 |
Anonymous (not verified) |
97.125.43.203 |
Raul Villanueva |
Proprietorship |
6901 SE 14th #71 |
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. |
2022-08-24 |
Raul Villanueva |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raul Villanueva |
deb@picowa.com |
self |
Des Moines |
Polk |
IA |
Debra Stratton |
Kelly Denger |
Signed |
1286 |
2022-08-26 09:09 |
Anonymous (not verified) |
97.125.43.203 |
Daniel Lugo |
Proprietorship |
1217 Harold Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-24 |
Daniel Lugo |
deb@piciowa.com |
Des Mpines |
Polk |
IA |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel LUgo |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
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 |
1315 |
2022-09-20 13:11 |
Anonymous (not verified) |
173.17.128.203 |
Leaffilter |
Proprietorship |
1595 Georgetown Rd., Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-20 |
Johnny Coker |
johnnycoker36@gmail.com |
Altoona |
Polk |
Iowa |
Travis Klapproth |
Emilie Klapproth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LeafFilter |
support@leafhome.com |
Sub contractor |
Grimes |
Polk |
Iowa |
Travis Klapproth |
Emilie Klapproth |
Signed |
1323 |
2022-09-28 22:45 |
Anonymous (not verified) |
74.51.212.66 |
OUTDOOR MODERN CONCEPTS LLC |
Limited Liability Company |
2520 RIVER MEADOWS DR., 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. |
2022-09-28 |
CHRISTIAN RUBIO |
RUBIOCH39@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
AMANDA DUPRE |
DARCI CLARK |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JENNIFER B. CHAVEZ-RIVERA |
JENNIFER.CHAVEZ-RIVERA@BROWNWINICK.COM |
ATTORNEY |
DES MOINES |
POLK |
IOWA |
AMANDA DUPRE |
DARCI CLARK |
Signed |
1339 |
2022-10-18 14:14 |
Anonymous (not verified) |
97.125.41.64 |
Juan Buenrostro |
Proprietorship |
2122 E 39th 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. |
2022-10-18 |
Juan Buenrostro |
juanjosebuenrostro@gmail.com |
Des Moines |
Polk |
IA |
Juan Buenrostro |
Kelly gonzalez buenrostro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Regional recruiter |
Kansas City |
Clay |
Missouri |
Jordan nisiewicz |
Jordan loyd |
Signed |
1340 |
2022-10-18 17:03 |
Anonymous (not verified) |
166.181.89.97 |
Stevens mobile welding services LLC |
Limited Liability Company |
5645 se 56th st. Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-18 |
Daniel Robert Stephens |
dannystephens303@gmail.com |
Carlisle |
Polk |
Iowa |
Nikita Marie Knapp |
Stacy Robin Stephens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Robert Stephens |
dannystephens303@gmail.com |
Owner |
Carlisle |
Polk |
Iowa |
Nikita Marie Knapp |
Stacy Robin Stephens |
Signed |
1343 |
2022-10-25 11:25 |
Anonymous (not verified) |
97.125.43.203 |
Midwest Pro Construction LLC |
Limited Liability Company |
1000 SE 11th St Apt 3202 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-17 |
Laura Garcia |
deb@piciowa.com |
Grimes |
polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura Garcia |
deb@piciowa.com |
self |
Grimes |
Polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
1356 |
2022-11-02 08:21 |
Anonymous (not verified) |
174.215.249.84 |
Leaf home solutions |
Proprietorship |
1595 Georgetown Road, Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-02 |
Micheal Wills |
mwills5304@gmail.com |
Granger |
Polk |
IA |
Bryanna Wills |
Andrew Vannausdle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryanna Wills |
bryannawills725@gmail.com |
None |
Granger |
Polk |
IA |
Andrew Vannausdle |
Micheal Wills |
Signed |
1359 |
2022-11-04 10:48 |
Anonymous (not verified) |
173.18.22.217 |
Lewis Enterprises |
Limited Liability Company |
2723 Witmer Street 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. |
2022-11-04 |
Corey Lewis |
coreyboy1990@gmail.com |
Des Moines |
Polk |
Iowa |
Kelly Coluzzi |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Lewis |
coreyboy1990@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Kelly Coluzzi |
Erick Schuldt |
Signed |
1361 |
2022-11-07 09:14 |
Anonymous (not verified) |
65.144.174.26 |
Rm Tile Marble LLC |
Limited Liability Company |
2051 King Ave Apt 1, 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. |
2022-11-07 |
Tony Funes |
balmore.funes76@icloud.com |
Des Moines |
Polk |
IA |
Osman Sarceno Gonzalez |
Nelson Hermanez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RM Tile Marble LLC |
balmore.funes76@icloud.com |
Self |
Des Moines |
Polk |
IA |
Osman Sarceno Gonzalez |
Nelson Hermanez |
Signed |
1367 |
2022-11-11 11:06 |
Anonymous (not verified) |
173.29.231.17 |
Sosa Flooring |
Proprietorship |
2310 NE 16TH Ankeny, Iowa 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-11 |
Zeferino Alcantara Sosa |
sunnysosa@aol.com |
Ankeny |
Polk |
Iowa |
Ashley Temple |
Sunny Sosa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zeferino Alcantara Sosa |
sunnysosa@aol.com |
OWNER |
Ankeny |
Polk |
Iowa |
Ashley Temple |
Sunny Sosa |
Signed |
1368 |
2022-11-11 11:58 |
Anonymous (not verified) |
173.29.231.17 |
Marcelino Gutierrez |
Proprietorship |
1705 Des Moines Street, Des Moines, Iowa 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-11 |
Marcelino Gutierrez |
lifestylefloors20@gmail.com |
Des Moines |
Polk |
Iowa |
Jerry Downing |
Ashley Temple |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcelino Gutierrez |
Lifestylefloors20@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Jerry Downing |
Ashley Downing |
Signed |
1369 |
2022-11-11 13:02 |
Anonymous (not verified) |
173.29.231.17 |
Salvador Cardenas |
Limited Liability Company |
5206 SE 31st Street, Des Moines, Iowa 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. |
2022-11-11 |
Salvador Cardenas |
salvadorcardenas16@icloud.com |
Des Moines |
Polk |
Iowa |
Omar Gonzalez |
Omar Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Salvador Cardenas |
salvadorcardenas16@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Omar Gonzalez |
Omar Gonzalez |
Signed |
1377 |
2022-11-21 13:06 |
Anonymous (not verified) |
166.181.84.102 |
Leaf home solutions |
Proprietorship |
1595 George Town road Hudson Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-21 |
Christopher da von carpenter |
chris.carpenter9595@icloud.com |
Pleasant hill |
Polk |
Iowa |
Clara Francis carpenter |
Thrinadh gutta |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher da von carpenter |
chris.carpenter9595@icloud.com |
Self |
Pleasant hill |
Polk |
Iowa |
Clara Francis carpenter |
Thrinadh gutta |
Signed |
1384 |
2022-12-08 13:11 |
Anonymous (not verified) |
172.58.81.43 |
Sehic G&S, LLC. |
Limited Liability Company |
4201 62nd st apt 4 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. |
2022-12-09 |
Bajro sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
1393 |
2022-12-13 12:45 |
Anonymous (not verified) |
50.82.133.22 |
Ponderosa Outdoor |
Limited Liability Partnership |
104 Vista Dr Montezuma, Ia 50171 |
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. |
2022-12-13 |
Daniel Deaver |
ponderosaoutdoor@gmail.com |
Altoona |
Polk |
Iowa |
Faith Deaver |
Jessi Perkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Deaver |
ponderosaoutdoor@gmail.com |
self |
Altoona |
Polk |
Iowa |
Faith Deaver |
Jessi Perkins |
Signed |
1395 |
2022-12-15 08:02 |
Anonymous (not verified) |
172.58.84.122 |
Sehic G&S, LCC |
Limited Liability Company |
4201 62nd st Urbandale iowa 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. |
2022-12-15 |
Bajro sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
Bajro |
Bajro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Bajro |
Bajro |
Signed |