1625 |
2023-05-04 14:07 |
Anonymous (not verified) |
94.188.207.228 |
Extreme Repair, LLC |
Limited Liability Company |
300 North Carthage St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-04 |
Tony Cleveland |
extremerepair1@yahoo.com |
EXIRA, IA |
Audubon |
United States |
Katherine Cleveland |
Isaac Kommes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Extreme Repai,r LLC |
extremerepair1@yahoo.com |
Self |
EXIRA, IA |
Audubon |
United States |
Katherine Cleveland |
Isaac Kommes |
Signed |
1626 |
2023-05-05 11:16 |
Anonymous (not verified) |
94.188.205.166 |
I HAWK BUILDERS LLC |
Limited Liability Company |
1417 INDIAN HILLS DR SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-05 |
BEN BRANT |
babrant99@yahoo.com |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BEN BRANT |
joel@walkerinsuranceia.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1628 |
2023-05-09 08:00 |
Anonymous (not verified) |
94.188.205.175 |
Servin Drywall |
Proprietorship |
6311 Underwood Ave SW, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-09 |
Arcel Servin |
arcelservin77@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Rolandas Bitanas |
Kirk Strunk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arcel Servin |
arcelservin77@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Rolandas Bitanas |
Kirk Strunk |
Signed |
1631 |
2023-05-09 10:13 |
Anonymous (not verified) |
94.188.207.229 |
Steve Stratton |
Proprietorship |
208 SE 5th St 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. |
(1) I am not electing the employers’ liability coverage. |
2023-04-01 |
Steve Stratton |
deb@piciowa.com |
Grimes |
Polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Stratton |
deb@piciowa.com |
self |
Grimes |
Polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
1632 |
2023-05-09 11:10 |
Anonymous (not verified) |
94.188.205.177 |
MM Drywall LLC Moises Melo Santiago |
Proprietorship |
7500 Bloomfield Road Lot 78 |
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. |
2023-03-01 |
Moises Melo Santiago |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MM Drywall LLC Moises Melo Santiago |
deb@piciowa.com |
self |
Des Moines |
polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
1634 |
2023-05-10 07:21 |
Anonymous (not verified) |
94.188.205.174 |
KS Drywall |
Proprietorship |
404 E Jayne Street Lone Tree, IA 52755 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Kirk Strunk |
kirkstrunk@gmail.com |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kirk Strunk |
kirkstrunk@gmail.com |
Self |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1635 |
2023-05-10 07:25 |
Anonymous (not verified) |
94.188.205.166 |
Chris Hay |
Proprietorship |
4911 Sutliff Rd Solon, IA 52333 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Christopher A Hay |
hay2u2@windstream.net |
Solon |
Johnson |
Iowa |
Brad Bower |
Kirk Strunk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Hay |
hay2u2@windstream.net |
Self |
Solon |
Johnson |
Iowa |
Brad Bower |
Kirk Strunk |
Signed |
1636 |
2023-05-10 07:31 |
Anonymous (not verified) |
94.188.205.167 |
Brad Bower Drywall LLC |
Limited Liability Company |
209 Northridge West Branch, IA 52358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Bradley Bower |
bbower74@gmail.com |
West Branch |
Cedar |
Iowa |
Kirk Strunk |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brad Bower |
bbower74@gmail.com |
Self |
West Branch |
Cedar |
Iowa |
Kirk Strunk |
Chris Hay |
Signed |
1637 |
2023-05-10 15:39 |
Anonymous (not verified) |
94.188.207.230 |
Carly Roskop |
Proprietorship |
7706 Hampshire Ct NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Carly Roskop |
carlyroskop@gmail.com |
Cedar Rapids |
IA |
United States |
Dustin Roskop |
Tracy Petrak |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carly Roskop |
carlyroskop@gmail.com |
Self |
Cedar Rapids |
IA |
United States |
Dustin Roskop |
Tracy Petrak |
Signed |
1638 |
2023-05-11 07:33 |
Anonymous (not verified) |
94.188.205.177 |
HV Drywall LLC |
Proprietorship |
1991 Holiday Rd, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Jose Jesus Hernandez |
jh80292@gmail.com |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Jesus Hernandez |
jh80292@gmail.com |
self |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
1639 |
2023-05-11 07:39 |
Anonymous (not verified) |
94.188.205.175 |
JYC Drywall LLC |
Proprietorship |
1034 Grand Ave, Muscatine, IA 52761 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Anastacio Zamarripa |
1zama0081@gmail.com |
Muscatine |
Louisa |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anastacio Zamarripa |
1zama0081@gmail.com |
Self |
Muscatine |
Louisa |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
1640 |
2023-05-11 07:42 |
Anonymous (not verified) |
94.188.205.168 |
Ibarra Drywall LLC |
Proprietorship |
1991 Holiday Rd, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Self |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
1641 |
2023-05-11 13:40 |
Anonymous (not verified) |
94.188.207.228 |
Mike Weigel Construction, LLC |
Limited Liability Company |
2528 Dalton St, Ames IA 50010-1151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Michael Patrick Weigel |
mikeweigelconstruction@gmail.com |
Ames |
Story |
Iowa |
Brenda Marie Weigel |
Piper Rylee Weigel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Patrick Weigel |
mikeweigelconstruction@gmail.com |
Self |
Ames |
Story |
Iowa |
Brenda Marie Weigel |
Piper Rylee Weigel |
Signed |
1642 |
2023-05-12 07:29 |
Anonymous (not verified) |
94.188.205.169 |
HARI SWAMI LLC |
Limited Liability Company |
2759 Mt Pleasant St, Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
BRANDON KELLY |
MARKWILLIAMSPRO@GMAIL.COM |
FRUIT HEIGHTS |
DAVIS |
UTAH |
MARK WILLIAMS |
GREG VANCAMP |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BRANDON KRLLY |
MARKWILLIAMSPRO@GMAIL.COM |
SELF |
FRUIT HEIGHTS |
DAVIS |
UTAH |
MARK WILLIAMS |
GREG VANCAMP |
Signed |
1643 |
2023-05-12 07:56 |
Anonymous (not verified) |
94.188.205.169 |
Smooth Finish Drywall |
Proprietorship |
3111 115th Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
Seth T Mize II |
stmize@hotmail.com |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth T Mize II |
stmize@hotmail.com |
Self |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1644 |
2023-05-12 07:59 |
Anonymous (not verified) |
94.188.205.176 |
Blue Ribbon Drywall |
Proprietorship |
3025 Peaceful Dr Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
Seth Mize Sr |
stmize@hotmail.com |
Riverside |
Washington |
Iowa |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Mize Sr |
stmize@hotmail.com |
Self |
Riverside |
Washington |
Iowa |
Brad Bower |
Chris Hay |
Signed |
1645 |
2023-05-12 14:48 |
Anonymous (not verified) |
94.188.207.225 |
VL Drywall LLC |
Limited Liability Company |
1608 6th Ave SE Cedar Rapids |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
LESLIE LEYVA |
lleyva9696@gmail.com |
Cedar Rapids |
LINN |
Iowa |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leslie Leyva |
lleyva9696@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1646 |
2023-05-15 13:13 |
Anonymous (not verified) |
94.188.207.224 |
Aspen leaf Painting |
Limited Liability Company |
3846 Lower Beaver 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. |
2023-05-15 |
Michael Patrick Vajda |
m.p.vajda@gmail.com |
Des Moines |
Polk |
IA |
Patrick Vajda |
Mike Vajda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Vajda |
m.p.vajda@gmail.com |
Self |
Des Moines |
Polk |
IA |
Mike Vajda |
Michael Vajda |
Signed |
1648 |
2023-05-16 08:16 |
Anonymous (not verified) |
94.188.205.169 |
Hernandez Drywall |
Proprietorship |
2001 8th St Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-16 |
Gerardo Hernandez |
gerardohernandez56u@gmail.com |
Coralville |
Johnson |
Iowa |
Brad Bower |
Kirk Strucnk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerardo Hernandez |
gerardohernandez56u@gmail.com |
Self |
Coralville |
Johnson |
iowa |
Brad Bower |
Kirk Strunk |
Signed |
1653 |
2023-05-18 09:45 |
Anonymous (not verified) |
94.188.205.166 |
Darwin Gonzales Rodriguez |
Proprietorship |
511 5th Street NE Belmond IA 50421 |
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. |
2022-04-10 |
Darwin Gonzales Rodriguez |
office.seamlesspros@icloud.com |
Belmond |
Wright |
Iowa |
Soila Perez |
Keith Clabaugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darwin Gonzales Rodriguez |
office.seamlesspros@icloud.com |
Self |
Belmond |
Wright |
Iowa |
Soila Perez |
Keith Clabaugh |
Signed |
1655 |
2023-05-19 14:19 |
Anonymous (not verified) |
94.188.207.229 |
Cutting Edge Concrete LLC |
Limited Liability Company |
325 Linn St, Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-19 |
Joel Waltz |
joel@cuttingedgeiowa.com |
Boone |
Boone |
Iowa |
Robert Simmons |
Deb Ernst |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Waltz |
joel@cuttingedgeiowa.com |
Self |
Boone |
Boone |
IA |
Robert Simmons |
Deb Ernst |
Signed |
1656 |
2023-05-22 11:48 |
Anonymous (not verified) |
94.188.205.169 |
Cesar Arroyo |
Proprietorship |
2207 Lisa Drive, Webster City IA 50595 |
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. |
2022-04-18 |
Cesar Arroyo |
office.seamlesspros@icloud.com |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Arroyo |
office.seamlesspros@icloud.com |
Self |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
1658 |
2023-05-23 09:56 |
Anonymous (not verified) |
94.188.205.168 |
M&D Webster Construction Inc |
Proprietorship |
1012 Creek Street Webster City IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
David Gomez |
office.seamlesspros@icloud.com |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Gomez |
office.seamlesspros@icloud.com |
Self |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
1659 |
2023-05-23 13:39 |
Anonymous (not verified) |
94.188.205.168 |
Rosendo Mora |
Proprietorship |
222 E Webster Street, Goldfield IA 50542 |
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 |
Rosendo Mora |
office.seamlesspros@icloud.com |
Goldfield |
Wright |
Iowa |
Anthony Buck |
Troy Knutson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rosendo Mora |
office.seamlesspros@icloud.com |
Self |
Goldfield |
Wright |
Iowa |
Anthony Buck |
Troy Knutson |
Signed |
1664 |
2023-05-25 13:18 |
Anonymous (not verified) |
94.188.207.227 |
Jason Vreeman |
Proprietorship |
5571 170th St sibley 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. |
2023-05-25 |
Jason Vreeman |
jvreeman21@gmail.com |
Sibley |
Osceola |
IA |
Katie Vreeman |
Jerry vreeman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Vreeman |
jvreeman21@gmail.com |
Self |
Sibley |
Osceola |
IA |
Katie Vreeman |
Jerry vreeman |
Signed |
1667 |
2023-05-29 22:31 |
Anonymous (not verified) |
94.188.207.226 |
All J Acres |
Limited Liability Company |
13522 120th Ave, Ottumwa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-26 |
Jonathan Bunt |
jonbunt@gmail.com |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Bunt |
jonbunt@gmail.com |
Self |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
1672 |
2023-06-01 15:16 |
Anonymous (not verified) |
94.188.207.224 |
Raudel Correa Correa |
Proprietorship |
1924 23rd 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. |
2023-06-01 |
Raudel Correa Correa |
correaraudel6@gmail.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raudel Correa Correa |
correaraudel6@gmail.com |
self |
DM |
Polk |
IA |
Den Stratton |
Kelly Denger |
Signed |
1679 |
2023-06-06 08:27 |
Anonymous (not verified) |
94.188.205.174 |
Remys Drywall LLC |
Proprietorship |
42 Hoover Blvd West Branch, IA 52358 |
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. |
2023-06-06 |
Remigio M Juan |
remmateojuan1997@gmail.com |
West Branch |
Cedar |
IA |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Remigio M Juan |
remmateojuan1997@gmail.com |
Self |
West Branch |
Cedar |
IA |
Brad Bower |
Chris Hay |
Signed |
1682 |
2023-06-08 17:55 |
Anonymous (not verified) |
94.188.205.174 |
Jared hoffman |
Proprietorship |
22429 250th st carroll IA 5140q |
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. |
2023-06-06 |
Jared Hoffman |
jhoffman@live.com |
Carroll |
Carroll |
Iowa |
Jeff dentlinger |
Brian babb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Hoffman |
jhoffman@live.com |
Self |
Carroll |
Carroll |
Iowa |
Jeff dentlinger |
Brian babb |
Signed |
1687 |
2023-06-12 16:23 |
Anonymous (not verified) |
94.188.207.229 |
Jose Manuel Sanchez Loreto |
Proprietorship |
108 North Hawthorn Drive Altoona, Iowa 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. |
2023-06-12 |
Jose Manual Sanzhez Loreto |
jjanna1226@gmail.com |
Altoona |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Manuel Sanchez Loreto |
jjana1226@gmail.com |
self |
Altoona |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1692 |
2023-06-15 15:20 |
Anonymous (not verified) |
94.188.207.228 |
Javier Rodriguez |
Proprietorship |
1512 18th St Des Moines, 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. |
2023-06-14 |
Javier A Rodriguez |
R.Javier14@gmail.com |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier A Rodriguez |
R.Javier14@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
1693 |
2023-06-16 11:37 |
Anonymous (not verified) |
94.188.207.230 |
Anthony Scroggins |
Proprietorship |
301 SE 11th Street , Unit 807 |
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. |
2023-06-16 |
Anthony Scroggins |
scroggins710@gmail.com |
Grimes |
Polk |
IA |
Cody Wavada |
Nate Duden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Scroggins |
scroggins710@gmail.com |
Self |
Grimes |
Polk |
IA |
Cody Wavada |
Nate Duden |
Signed |
1700 |
2023-06-22 14:53 |
Anonymous (not verified) |
94.188.205.166 |
James Trotter |
Limited Liability Company |
1341 Cachelin Dr Carter Lake IA 51510 |
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. |
2023-06-22 |
James Trotter |
trotterwizard@gmail.com |
Carter Lake |
Pottawattamie |
IA |
Shelby Schultz |
Elora Trotter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Trotter |
trotterwizard@gmail.com |
Self |
Carter Lake |
Pottawattamie |
IA |
Shelby Schultz |
Elora Trotter |
Signed |
1702 |
2023-06-22 22:57 |
Anonymous (not verified) |
94.188.207.230 |
A&M Consulting LLC |
Limited Liability Company |
1208 5th Ave, North Humboldt Iowa, 50548 |
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. |
2023-06-22 |
maureen Waweru |
maureenrealtyaz@yahoo.com |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maureen Waweru |
maureenrealtyaz@yahoo.com |
Self |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
1703 |
2023-06-23 08:58 |
Anonymous (not verified) |
94.188.205.175 |
Then & Kramer Construction, Inc |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
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. |
2023-06-22 |
Shannon Kramer |
dparsons@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
1704 |
2023-06-23 09:00 |
Anonymous (not verified) |
94.188.205.166 |
THen & Kramer Construcion, Inc. |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
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. |
2023-06-22 |
Dakota Kramer |
dparsons@english-insurance.com |
Epworth, |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
1711 |
2023-06-26 16:50 |
Anonymous (not verified) |
94.188.207.224 |
Innovative Behavioral Therapy, LLC |
Limited Liability Company |
915 Main St. 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. |
2023-06-26 |
Ashley Andrew |
ashley@innovativebehavioraltherapy.com |
Adel |
Dallas |
Iowa |
Thomas Atherton |
Brenda Barto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ashley Andrew |
ashley@innovativebehavioraltherapy.com |
Self |
Adel |
Dallas |
Iowa |
Thomas Atherton |
Brenda Barto |
Signed |
1714 |
2023-06-27 09:14 |
Anonymous (not verified) |
94.188.205.167 |
Meier Trucking LLC |
Limited Liability Company |
35032 308th St, Bellevue, IA 52031 |
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. |
2023-06-14 |
Brandon Meier |
meierturcking87@yahoo.com |
Bellevue |
Jackson |
Iowa |
Susan Miller |
Nicole Mensen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Meier |
meiertrucking87@yahoo.com |
self |
Bellevue |
Jackson |
Iowa |
Susan Miller |
Nicole Mensen |
Signed |
1718 |
2023-06-29 12:36 |
Anonymous (not verified) |
94.188.205.166 |
Aidan Obermueller |
Proprietorship |
2520 N Grandview Avenue, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-27 |
Aidan Obermueller |
aidanobermueller@icloud.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aidan Obermueller |
aidanobermueller@icloud.com |
self |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miler |
Signed |
1721 |
2023-07-06 08:19 |
Anonymous (not verified) |
94.188.207.228 |
Bradford Alexander Carr |
Proprietorship |
3349 Southgate Ct SW Ste 101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-06 |
Bradford Alexander Carr |
alex.carr@thrivent.com |
Coralville |
Johnson |
Iowa |
Gaylon Heetland |
David King |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bradford Alexander Carr |
alex.carr@thrivent.com |
Self |
Coralville |
Johnson |
Iowa |
Gaylon Heetland |
David King |
Signed |
1724 |
2023-07-06 19:34 |
Anonymous (not verified) |
94.188.207.223 |
ALDO B. CANCINO HERNANDEZ |
Proprietorship |
2524 SHADOW CREEK LN, 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. |
2023-07-06 |
ALDO B. CANCINO HERNANDEZ |
aldo94.cansino@gmail.com |
DES MOINES |
USA |
IOWA |
JUAN M. MAYORGA |
OFELIA BUSTILLOS VALENZUELA |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ALDO B. CANCINO HERNANDEZ |
aldo94.cancino@gmail.com |
SELF |
DES MOINES |
USA |
IOWA |
JUAN M. MAYORGA |
OFELIA BUSTILLOS VALENZUELA |
Signed |
1726 |
2023-07-07 18:22 |
Anonymous (not verified) |
94.188.205.168 |
D&E LLC DBA Kanesville Valley |
Limited Liability Company |
P.O. Box 337 Council Bluffs, IA, 51502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Damien Joseph Shull |
damienshull@gmail.com |
Omaha |
Douglas |
Nebraska |
Angela Shull |
John Shull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Damien Joseph Shull |
damienshull@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Angela Shull |
John Shull |
Signed |
1727 |
2023-07-07 18:26 |
Anonymous (not verified) |
94.188.205.169 |
D&E LLC DBA Kanesville Valley |
Limited Liability Company |
P.O. Box 337 Council Bluffs, IA, 51502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Edward Gregory |
eddegregory@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Gregory |
eddegregory@gmail.com |
Self |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
Signed |
1732 |
2023-07-10 13:22 |
Anonymous (not verified) |
94.188.207.224 |
Jovan Guerrero |
Proprietorship |
2887 Jaden Lane Norwalk, Iowa 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. |
2023-07-10 |
Jovan Guerrero |
deb@piciowa.com |
Norwalk |
Warren |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jovan Guerrero |
deb@piciowa.com |
self |
Norwalk |
Warren |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1738 |
2023-07-11 10:51 |
Anonymous (not verified) |
94.188.207.224 |
Augustin Santos |
Proprietorship |
109 Loomis 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. |
2022-01-05 |
Augustin Santos |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Augustin Santos |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
1741 |
2023-07-12 09:38 |
Anonymous (not verified) |
94.188.207.230 |
Jose Tavares |
Proprietorship |
1175 Office Park Road Apt 109 WDM IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-28 |
Jose Tavares |
deb@piciowa.com |
WDM |
Polk |
IA |
Martin Pin on |
Deb Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Tavares |
deb@piciowa.com |
self |
WDM |
Polk |
IA |
Martin Pinon |
Deb Stratton |
Signed |
1743 |
2023-07-13 10:24 |
Anonymous (not verified) |
94.188.207.225 |
Sindi Merida Alvarez MA Consttuction LLC |
Proprietorship |
2048 Lyon St DM, 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. |
2022-08-24 |
Sindi Merida-Alvarez dba MA Construction LLC |
deb@piciowa.com |
Des Moines |
Polk |
IA |
Debra Stratton` |
kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sindi Merida Alvarez dba MA Construction LLC |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1745 |
2023-07-13 16:20 |
Anonymous (not verified) |
94.188.205.174 |
Gaytan Framing LLC |
Limited Liability Company |
4745 NE 27th Ct |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-13 |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
Des Moines |
Erwin Quintanilla |
Misael Balleza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edwin Quintanilla |
Misael Balleza |
Signed |
1749 |
2023-07-17 10:52 |
Anonymous (not verified) |
94.188.205.175 |
Zenon Loreto |
Proprietorship |
1324 E 29th 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. |
2021-07-17 |
Zenon Loreto |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Inspro in 2019 |
Inspro in 2019 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zenon Loreto |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro in 2019 |
Inspro in 2019 |
Signed |
1750 |
2023-07-17 11:00 |
Anonymous (not verified) |
94.188.205.166 |
Mario Flores |
Proprietorship |
2101 E Virginia Ave. Apt 1 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. |
2021-07-22 |
Mario Zubia Flores |
deb@piciowa.com |
Des Moiines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Zubia Flores |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |