1039 |
2022-04-11 14:33 |
Anonymous (not verified) |
199.120.121.97 |
Panama Electric |
Proprietorship |
106 S Railway Panama IA 51562 |
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. |
2022-04-11 |
Dan Wingert |
danwingert@fmctc.com |
Panama |
Shelby |
IA |
Laura Wingert |
Sylvan Kenkel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Wingert |
danwingert@fmctc.com |
Self |
Panama |
Shelby |
IA |
Laura Wingert |
Sylvan Kenkel |
Signed |
1151 |
2022-06-13 09:29 |
Anonymous (not verified) |
208.126.52.58 |
Ronald D. Heneke |
Proprietorship |
PO Box 114 |
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. |
2022-06-13 |
Ronald D. Heneke |
rheneke@email.com |
Delmar |
Clinton |
Iowa |
Mary S. O’Dell |
Neal J. Damm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald D. Heneke |
rheneke@email.com |
Self |
Delmar |
Clinton |
Iowa |
Mary S. O’Dell |
Neal J. Damm |
Signed |
32 |
2020-01-08 08:31 |
Anonymous (not verified) |
199.120.118.90 |
BOBCATS LLC |
Limited Liability Company |
1860 505TH ST LINN GROVE 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. |
2019-11-18 |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
OWNER |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
Signed |
1263 |
2022-08-16 13:18 |
Anonymous (not verified) |
70.96.153.153 |
Sinnott Solutions LLC |
Limited Liability Company |
1798 643rd Ln, Albia, IA 52531 |
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. |
2022-08-16 |
Kyle Sinnott |
kyle.s@optionsexteriors.com |
Albia |
Monroe County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Sinnott |
kyle.s@optionsexteriors.com |
Owner/Self |
Albia |
Monroe |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
144 |
2020-04-29 11:20 |
Anonymous (not verified) |
65.158.103.107 |
Symbiotic Gardens LLC |
Limited Liability Company |
3403 Dubuque Avenue 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. |
2020-04-29 |
Brandon Kam |
symbioticgardens@gmail.com |
Des Moines |
Polk |
Iowa |
Kathy Schulte |
Larry Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Kam |
symbioticgardens@gmail.com |
same |
Des Moines |
Polk |
Iowa |
Kathy Schulte |
Larry Johnson |
Signed |
1375 |
2022-11-18 10:21 |
Anonymous (not verified) |
166.181.87.119 |
Heff Built Construction LLC |
Limited Liability Company |
1403 Kodiak Dr NW Cedar Rapids, IA 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-18 |
Jacob Heffernen |
jheffernen@gmail.com |
Cedar Rapids |
Linn |
IA |
Kyle Reid |
Amanda Frese |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Heffernen |
jheffernen@gmail.com |
N/A |
Cedar Rapids |
Linn |
IA |
Kyle Reid |
Amanda Frese |
Signed |
256 |
2020-09-14 09:38 |
Anonymous (not verified) |
66.188.136.150 |
Steven Headlee |
Proprietorship |
671 Metaire Drive Apt. A, Greenwood, IN 46143 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-14 |
Steven Headlee |
kschumacher@tricorinsurance.com |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Headlee |
kschumacher@tricorinsurance.com |
Same |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
1487 |
2023-02-27 22:12 |
Anonymous (not verified) |
94.188.207.224 |
Panda garden |
Proprietorship |
105 2nd Ave se cresco ia 52136 |
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. |
2022-02-10 |
Jing Chen |
jingchen9968@gmail.com |
Cresco |
Howard |
Iowa |
Leyang Zhou |
Guy Chen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jing Chen |
jingchen9968@gmail.com |
Self |
Cresco |
Howard |
Iowa |
Leyang zhou |
Guy Chen |
Signed |
368 |
2021-01-21 15:12 |
Anonymous (not verified) |
97.125.235.64 |
R. A. Snow Removals, Inc |
Proprietorship |
525 7th St NW, Altoona, IA 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-21 |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
IA |
United States |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
1822 |
2023-08-29 11:52 |
Anonymous (not verified) |
94.188.207.224 |
Ellison building and repair |
Limited Liability Company |
2722 645th ave moravia iowa 52571 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-18 |
Keeton Ellison |
keeton2005@gmail.com |
Moravia |
Appanoose |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sammy Ellison |
sammyllsn@yahoo.com |
Mom |
Moravia |
Monroe |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
1599 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.229 |
luis contreras |
Proprietorship |
433 8th ave sw |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-25 |
luis contreras |
luisayala781@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luis contreras |
luisayala781@gmail.com |
N/A |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
480 |
2021-04-14 15:58 |
Anonymous (not verified) |
65.103.82.36 |
Home Cleaning Services |
Proprietorship |
1448 w 13th St Davenport IA 52804 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Jolene Lyn Brown |
j@gmail.com |
davenport |
scott |
IA |
Jamie Swanson |
Andrew Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jolene Brown |
j@gmail.com |
owner |
davenport |
Scott |
IA |
Jamie Swanson |
andrew Swanson |
Signed |
1934 |
2023-12-01 22:43 |
Anonymous (not verified) |
94.188.207.224 |
wasabi johnston llc |
Limited Liability Company |
7115 ridgedale ct, johnston, IA, 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
wenhui chen |
michaelchen@wasabidsm.com |
johnston |
polk |
Iowa |
wen Zheng |
Jenna Yu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
wenhui chen |
michaelchen@wasabidsm.com |
owner |
johnston |
polk |
IOWA |
wen zheng |
Jenna Yu |
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 |
592 |
2021-07-29 16:44 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
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. |
2021-07-29 |
Adam Reth |
adam@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Reth |
adam@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Dustin Fessler |
Signed |
2046 |
2024-02-15 11:29 |
Anonymous (not verified) |
94.188.205.175 |
Ervin Cabrera Mendez |
Proprietorship |
4822 Meadowlark Lane, Sioux City, Iowa 51106 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Ervin Cabrera Mendez |
ervincabrera89@gmail.com |
Sioux City |
Woodbury |
Iowa |
Kyle Buum |
David Jacobs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ervin Cabrera Mendez |
ervincabrera89@gmail.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Kyle Buum |
David Jacobs |
Signed |
704 |
2021-11-01 18:43 |
Anonymous (not verified) |
157.52.56.205 |
Martin Clip & Trim LLC |
Limited Liability Company |
204 Oak Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-30 |
Armin Harold Martin |
arminbonnie@aol.com |
Urbana |
Benton |
Iowa |
Melissa Linn Stieferman |
Bronna Mae Gubbels |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Armin Harold Martin |
arminbonnie@aol.com |
self |
Urbana |
Benton |
Iowa |
Melissa Linn Stieferman |
Bronna Mae Gubbels |
Signed |
2158 |
2024-04-17 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Mildred Lopez |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Mark Morrison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Mark Morrison |
Signed |
816 |
2021-12-30 09:56 |
Anonymous (not verified) |
174.199.83.133 |
Michael Fales |
Proprietorship |
1987 180th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-30 |
Michael Lee Fales |
Chubby__69@hotmail.com |
Canby |
Yellow Medicine |
Minnesota |
Tori Fales |
Jean Fales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Lee Fales |
Chubby__69@hotmail.com |
Owner |
Canby |
Yellow Medicine |
Minnesota |
Tori Fales |
Jean Fales |
Signed |
943 |
2022-03-03 13:49 |
Anonymous (not verified) |
192.95.125.191 |
B & R Enterprises LLC |
Limited Liability Company |
2850 73rd St, Newhall, IA 52315 |
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. |
2022-02-17 |
Ronald Jarrett |
ashlyn@3riversins.net |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ronald Jarrett |
brsirenguys@gmail.com |
Member of LLC |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
1055 |
2022-04-15 20:06 |
Anonymous (not verified) |
166.181.87.86 |
Steve MORRISON Trucking |
Proprietorship |
P.O. Box 66 105 N Elm Danville, IA 52623 |
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. |
2022-04-15 |
Stephen Dwight Morrison |
sdmt13@gmail.com |
Danville |
Des Mounes |
IA |
Jamie Brown |
William Samples |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Dwight Morrison |
sdmt13@gmail.com |
Owner |
Danville |
Des Moines |
IA |
Jamie Brown |
William Samples |
Signed |
1167 |
2022-06-23 09:56 |
Anonymous (not verified) |
74.84.106.106 |
Adam Wamsher |
Proprietorship |
1517 Ridge Crest Ct Knoxville, IA 50138 |
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 |
Adam Wamsher |
wamshera@hotmail.com |
Knoxville |
Marion |
Iowa |
Tina Owens |
Kim Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Wamsher |
wamshera@hotmail.com |
Self |
Knoxville |
Marion |
Iowa |
Tina Owens |
Kim Owens |
Signed |
48 |
2020-01-29 13:52 |
Anonymous (not verified) |
97.64.170.98 |
DARIN J. KESSLER |
Proprietorship |
1236 25TH ST AMES, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-29 |
DARIN J. KESSLER |
darinjkessler@gmail.com |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DARIN J. KESSLER |
darinjkessler@gmail.com |
SELF |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
1279 |
2022-08-22 13:17 |
Anonymous (not verified) |
50.83.54.168 |
Essex Family Construction |
Limited Liability Company |
290 Monmouth St SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Niki Essex |
essexfamilycontruction@outlook.com |
Cedar Rapids |
IA |
IA |
Josh Lasond |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niki Essex |
essexfamilycontruction@outlook.com |
same |
Cedar Rapids |
Iowa |
Iowa |
Josh Lasond |
Jordan Nisiewicz |
Signed |
160 |
2020-05-18 15:04 |
Anonymous (not verified) |
173.28.28.57 |
Angela Scanlan |
Proprietorship |
26436 320th Street, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-28 |
Angela Scanlan |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Angela Scanlan |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1391 |
2022-12-12 11:13 |
Anonymous (not verified) |
136.35.255.41 |
Snyder Roofing |
Proprietorship |
2343 ridge trail 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-12-12 |
Craig Snyder |
snyderroofingcr@gmail.com |
Cedar Rapids |
Linn county |
Iowa |
Jordan Loyd |
Charles Wood |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Charles Wood |
Jordan Loyd |
Signed |
272 |
2020-10-02 13:10 |
Anonymous (not verified) |
99.203.92.229 |
Batres Homes Renovation LLC |
Limited Liability Company |
3000 2nd Ave 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. |
2020-10-02 |
Gabriel Antonio Batres Huezo |
gabirlebatres7@gmail.com |
Des Moines |
Polk |
Iowa |
Blanca Silvia Leiva |
Luis Mariano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Walter Alexander Batres Huezo |
wbatres12@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Blanca Silvia Leiva |
Luis Mariano |
Signed |
1503 |
2023-03-07 12:45 |
Anonymous (not verified) |
94.188.205.177 |
Al's Roofing LLC |
Limited Liability Company |
P O Box 277 Lime Springs, 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. |
2022-04-18 |
John Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
384 |
2021-02-03 20:36 |
Anonymous (not verified) |
66.129.217.166 |
GIL Construction, LLC |
Limited Liability Company |
3107 M & W Crl |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Muscatine |
Iowa |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Owner |
North Liberty |
IA |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
1838 |
2023-09-12 10:48 |
Anonymous (not verified) |
94.188.207.224 |
OKOBOJI TSHIRT CENTER LLC |
Limited Liability Company |
PO BOX 158 ARNOLDS PARK, IA 51331 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-12 |
ADIR SEBAN |
PACIFIC513@YAHOO.COM |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ADIR SEBAN |
PACIFIC513@YAHOO.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1615 |
2023-04-27 17:42 |
Anonymous (not verified) |
94.188.207.227 |
John Anthony Davis |
Proprietorship |
P.O. Box 2551 Mountain View, AR 72560 |
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. |
2023-04-27 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Proprietor |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
496 |
2021-04-23 12:48 |
Anonymous (not verified) |
173.29.190.18 |
A+ Roofing and Siding Co |
Proprietorship |
1636 15th St Pl, Moline, IL 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-22 |
SHAWN HICKS |
APLUSROOFINGQCA@YAHOO.COM |
Milan |
IL |
United States |
deena hicks |
Mike Chandler |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
SHAWN HICKS |
APLUSROOFINGQCA@YAHOO.COM |
SELF/OWNER |
Milan |
IL |
United States |
deena hicks |
Mike Chandler |
Signed |
1950 |
2023-12-12 12:20 |
Anonymous (not verified) |
94.188.205.168 |
Central Iowa Welding & Repair |
Limited Liability Company |
13913 140th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Owner |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
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 |
608 |
2021-08-17 21:35 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
James D VanderBeek |
jvanderbeek@plbci.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
Zackery James VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Zackery J VanderBeek |
Signed |
2062 |
2024-02-29 08:25 |
Anonymous (not verified) |
94.188.205.169 |
Midwest Splicing LLC |
Limited Liability Company |
1803 N HALF BANK RD , Stringtown , OK 74569 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
James Xiong |
midwestsplicing71@yahoo.com |
Stringtown |
OKLAHOMA |
OKLAHOMA |
Vang Pao Chang |
Xia Vang |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Xiong |
midwestsplicing71@yahoo.com |
owner |
STRINGTOWN |
Oklahoma |
Oklahoma |
xia Vang |
Vang Pao Chang |
Signed |
720 |
2021-11-05 13:57 |
Anonymous (not verified) |
209.252.172.87 |
Rick Klemesrud Brookstin Flooring |
Proprietorship |
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. |
2020-05-23 |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Coralville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Self |
Croalville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
2174 |
2024-04-24 08:22 |
Anonymous (not verified) |
94.188.205.175 |
White's Floorcovering |
Proprietorship |
129 Hillcrest Dr. Biggsville, IL 61418 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ron White |
hntwhite@frontiernet.net |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron White |
hntwhite@frontiernet.net |
owner |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
832 |
2022-01-12 17:23 |
Anonymous (not verified) |
67.212.111.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 Cedar Falls, Iowa 50613 |
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. |
2022-01-13 |
Braden L Gray |
grayb2014@gmail.com |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Darren Dean Fanning |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Allen Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Darren Dean Fanning |
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 |
61 |
2020-02-13 08:44 |
Anonymous (not verified) |
71.28.216.94 |
Cyclone Captioning, Inc |
Proprietorship |
8866 W 122nd Street N, Mingo, IA 50168 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-13 |
Holli L. Schneider |
Hlschneid87@gmail.com |
Mingo |
Jasper |
IA |
Dan Herrin |
Minda Dearden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Holli Schneider |
hlschneid87@gmail.com |
President of Proprietorship |
Mingo |
Jasper |
IA |
Dan Herrin |
Minda Dearden |
Signed |
1292 |
2022-09-02 13:26 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
Limited Liability Company |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-02 |
Benjamin Darbro |
darbrob@gmail.com |
Iowa City |
Iowa |
United States |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
173 |
2020-06-04 11:22 |
Anonymous (not verified) |
167.142.93.121 |
Chad Hauschild dba Chad Hauschild Logging |
Proprietorship |
23864 190th St, Farmersburg, IA 52047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-04 |
Chad Hauschild |
michael@giffordinsurance.net |
Farmersburg |
Clayton |
Iowa |
Angela Keppler |
Kevin Lau |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Hauschild |
michael@giffordinsurance.net |
Self |
Farmersburg |
Clayton |
Iowa |
Angela Keppler |
Kevin Lau |
Signed |
1404 |
2023-01-03 15:26 |
Anonymous (not verified) |
173.20.50.85 |
Falcon Pride Properties, LLC |
Limited Liability Company |
1401 State Highway 57, Parkersburg, IA 50665 |
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. |
2022-12-23 |
Todd Thomas |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Thomas |
cmins_re@mchsi.com |
Owner |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
285 |
2020-10-21 16:24 |
Anonymous (not verified) |
66.188.136.150 |
Roger Cole |
Proprietorship |
30 Devon Dr. 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. |
2020-10-21 |
Roger cole |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger Cole |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
1516 |
2023-03-14 09:00 |
Anonymous (not verified) |
94.188.207.225 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
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. |
2023-03-14 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
397 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
1851 |
2023-09-22 12:36 |
Anonymous (not verified) |
94.188.207.229 |
MNM Construction |
Proprietorship |
3224 sw 12th place 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. |
2023-09-22 |
craig allen mccormick |
craigmccormick.6363@gmail.com |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
craig mccormick |
craigmccormick.6363@gmail.com |
self |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
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 |
509 |
2021-05-10 15:25 |
Anonymous (not verified) |
108.190.5.14 |
Shift Transport LLC |
Limited Liability Company |
4215 Kris Line Drive Waterloo, IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Damir Pajazetovic |
damirp2015@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Fata Pajazetovic |
Melda Pajazetovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adnan Pajazetovic |
adoni.shift@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Fata Pajazetovic |
Melda Pajazetovic |
Signed |