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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Employer: Type of Entity: Address of Employer's Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Understanding Confirmation: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness 1: Full Name of Witness 2: Signing Indication: Check either alternative (1) or (2): Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Employer of Authorized Agent: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
2145 2024-04-11 12:27 Anonymous (not verified) 94.188.205.177 Grinnell Web Services LLC Limited Liability Company 1902 Spring St, Grinnell IA 50112 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. 2024-04-11 Richard Ethington RDE326@rrmse.com Grinnell Poweshiek Iowa Lori Stratton Lisa Folkmann Signed (1) The employer does not elect the employers’ liability coverage. Richard Ethington rde326@rrmse.com self Grinnell poweshiek iowa lori stratton lisa folkmann Signed
2148 2024-04-15 11:15 Anonymous (not verified) 94.188.207.224 Derek Fetzer Proprietorship 360 250th St, 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. 2022-12-17 Dere W Fetzer kellylanz1967@gmail.com West Branch IA United States Maribelle Lund Carl Lund Signed (1) The employer does not elect the employers’ liability coverage. Derek Fetzer kellylanz1967@gmail.com Self West Branch IA United States Maribelle Lund Carl Lund Signed
2149 2024-04-15 11:20 Anonymous (not verified) 94.188.207.224 Grady Yeggy Proprietorship 211 3rd St. 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. 2022-12-11 Grady S Yeggy kellylanz1967@gmail.com Riverside IA United States Amanda Yeggy Leah Evans Signed (1) The employer does not elect the employers’ liability coverage. Grady S Yeggy kellylanz1967@gmail.com Self Riverside IA United States Amanda Yeggy Leah Yeggy Signed
2150 2024-04-15 12:07 Anonymous (not verified) 94.188.205.177 Todd E Holsteen Proprietorship 16015 Hwy 99, 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. 2022-11-28 Todd E Holsteen kellylanz1967@gmail.com Burlington IL United States David Steele Kari Holsteen Signed (1) The employer does not elect the employers’ liability coverage. Todd E Holsteen kellylanz1967@gmail.com Self Burlington IA United States David Steele Kari Holsteen Signed
2153 2024-04-15 21:59 Anonymous (not verified) 94.188.205.167 Ethan M Hoffman Proprietorship 1442 N. County RD 800, Hamilton, IL 62341 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Ethan M Hoffman kellylanz1967@gmail.com Hamilton IL United States Gay Hoffman Debra Kelley Signed (1) The employer does not elect the employers’ liability coverage. Ethan M Hoffman kellylanz1967@gmail.com Self Hamilton IL United States Gay Hoffman Debra Kelley Signed
2154 2024-04-16 08:05 Anonymous (not verified) 94.188.207.226 Lanz Pork Inc Proprietorship 12905 N 1050th Road, Macomb, IL 61455 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. 2022-08-02 Andrew M Riggins kellylanz1967@gmail.com Macomb IL United States Barb Coker Scott Caspall Signed (1) The employer does not elect the employers’ liability coverage. Andrew M Riggins kellylanz1967@gmail.com Self Macomb IL United States Barb Coker Scott Caspall Signed
2155 2024-04-16 08:13 Anonymous (not verified) 94.188.207.225 Andrew M Riggins Proprietorship 12905 N 1050th Road, Macomb, IL 61455 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. 2022-08-02 Andrew M Riggins kellylanz1967@gmail.com Macomb IL United States Barb Coker Scott Caspall Signed (1) The employer does not elect the employers’ liability coverage. Andrew M Riggins kellylanz1967@gmail.com Self Macomb IL United States Barb Coker Scott Caspall Signed
2157 2024-04-17 11:16 Anonymous (not verified) 94.188.205.168 LAKESIDE DETAILING LLC Limited Liability Company 249 EMERALD MEADOWS DR, 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. 2024-04-17 DYLAN MCHUGH 19DMCHUGH@GMAIL.COM ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. DYLAN MCHUGH 19DMCHUGH@GMAIL.COM SELF ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH 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
2159 2024-04-17 12:28 Anonymous (not verified) 94.188.207.229 Mildred Lopez Camacho 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 Jonathan Morales Signed (1) The employer does not elect the employers’ liability coverage. Mildred Lopez Camacho morrison.hpd@gmail.com Self Hampton Franklin IOwa Ixia Anduce Jonathan Morales Signed
2164 2024-04-19 13:52 Anonymous (not verified) 94.188.205.167 RKB Designs LLC Limited Liability Company 4333 Cedar St, Davenport, IA 52806 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. 2024-04-19 Ashley Rocca roccafive@gmail.com Davenport IA United States Nicholas Rocca Joni Long Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rocca roccafive@gmail.com Self Davenport IA United States Nicholas Rocca Joni Long Signed
2165 2024-04-19 14:05 Anonymous (not verified) 94.188.207.225 Apex Striping LLC Limited Liability Company 1325 Western Ave, cedar Falls, IA. 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. 2024-04-19 Chaz Ernest Torres admin@apexstripingia.com Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed (1) The employer does not elect the employers’ liability coverage. Chaz Ernest Torres admin@apexstripingia.com Self Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed
2170 2024-04-22 10:11 Anonymous (not verified) 94.188.207.224 Joy Ride Transport Limited Liability Company 3105 SE Miehe Drive, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Ted Cochran ted@ridejoyride.com Clive Dallas IA Lindsey Pace Carissa Gehrking Signed (1) The employer does not elect the employers’ liability coverage. Ted Cochran ted@ridejoyride.com Self Clive Dallas IA Lindsey Pace Carissa Gehrking Signed
2181 2024-04-25 15:41 Anonymous (not verified) 94.188.205.168 Ev's Ice Cream LLC Limited Liability Company 2205 1/2 S Center St, Marshalltown, IA 50158-5960 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. 2024-04-25 Kathryn Perry-Jenkins hawkeyesfan.22.kp@gmail.com Marshalltown Marshall IA Rebecca Houg Dakota Himes Signed (1) The employer does not elect the employers’ liability coverage. Kathryn Perry-Jenkins hawkeyesfan.22.kp@gmail.com Self Marshalltown Marshall IA Rebecca Houg Dakota Himes Signed
2183 2024-04-26 14:49 Anonymous (not verified) 94.188.205.168 Cory's Painting LLC Limited Liability Company Po Box 1161 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. 2024-04-01 Jared Birkenholz jareddrewb@gmail.com CEDAR FALLS IA United States Colton Blue Kari Houle Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self CEDAR FALLS IA United States Colton Blue Kari Houle Signed
2184 2024-04-26 15:03 Anonymous (not verified) 94.188.205.166 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. 2024-04-15 Joseph Abrahamson abrahamsonjd95@gmail.com Readlyn Bremer United States Colton Blue Kari Houle Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self Cedar Falls Blackhawk Iowa Colton Blue Kari Houle Signed
2187 2024-04-29 08:30 Anonymous (not verified) 94.188.207.226 Fran Stonework LLC Limited Liability Company 1222 E Seneca Ave Apt 7, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 Francisco Rodriguez Rios panchito941@icloud.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Francisco Rodriguez Rios panchito941@icloud.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
2189 2024-04-29 09:23 Anonymous (not verified) 94.188.207.225 Sals Home Improvements LLC Limited Liability Company 3750 NW Maple Ct Ankeny IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 Salvador Gomez salvadorg27@hotmail.com Ankeny Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Salvador Gomez salvadorg27@hotmail.com Self Ankeny Polk Iowa Fabiola Palomares Nathan Miller Signed
2192 2024-04-29 13:15 Anonymous (not verified) 94.188.205.166 ElmStreet Apothecary Limited Liability Company 320 W Kimberly Road #227 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. 2024-04-29 Erica McGee esalsbury07@gmail.com Bettendorf Scott Ia Jennifer West Julie Francis Signed (1) The employer does not elect the employers’ liability coverage. Erica McGee esalsbury07@gmail.com Self Bettendorf Scott Ia Jennifer West Julie Francis Signed
2194 2024-04-30 14:57 Anonymous (not verified) 94.188.207.223 Juan Raymundo Hernandez Proprietorship 3317 Scott Ave 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. 2024-01-25 Juan Raymundo Hernandez deb@piciowa.com Des Moines Poik Iowa Kelly Denger Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Juan Raymundo Hernandez deb@piciowa.com self Des Moines Polk Iowa Kelly Denger Debra Stratton Signed
2195 2024-04-30 15:31 Anonymous (not verified) 94.188.205.166 Jason Cooper Proprietorship 1181 Western Ave Stockton Iowa 52769 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. 2024-04-30 Jason cooper jvcpainting88@gmail.com Stockton IA United States Violet minssen Hope Bishop Signed (1) The employer does not elect the employers’ liability coverage. Jason cooper jvcpainting88@gmail.com Self Stockton IA United States Violet minssen Hope Bishop Signed
2196 2024-05-01 09:18 Anonymous (not verified) 94.188.207.230 Penaloza Stone LLC Limited Liability Company 1530 8th St Des Moines IA 50314 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. 2024-05-01 Javier Marcial Penaloza javiermarcial.jmp@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Javier Marcial Penaloza javiermarcial.jmp@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
2197 2024-05-02 09:30 Anonymous (not verified) 94.188.207.229 Melvin Osorio Proprietorship 3848 E 14th St Trlr 78, Des Moines IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-02 Melvin Osorio matamorosana56@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Melvin Osorio matamorosana56@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
2198 2024-05-02 11:26 Anonymous (not verified) 94.188.207.224 Sierra Stone LLC Limited Liability Company 2504 E 37th St Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-02 Daniel Nunez danieln2024@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Daniel Nunez danieln2024@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
2199 2024-05-03 13:27 Anonymous (not verified) 94.188.207.228 Polar Delights LLC DBA Twists Ice Cream Limited Liability Company 110 S 9th Ave Eldridge IA 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-03 Anna Kokity amkokity@gmail.com Moline Rock Island IL Ashley Schwien Kasey Lange Signed (1) The employer does not elect the employers’ liability coverage. Anna Kokity amkokity@gmail.com self Moline Rock Island IL Ashley Schwien Kasey Lange Signed
2202 2024-05-06 11:36 Anonymous (not verified) 94.188.207.224 Neil Wedeking Proprietorship 408 Maple St, Nemaha, IA 50567 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. 2024-05-06 Neil Douglas Wedeking nandjwedeking@frontiernet.net Nemaha Sac Iowa Joseph McCollum Heather Husman Signed (1) The employer does not elect the employers’ liability coverage. Neil Wedeking nandjwedeking@frontiernet.net Self Nemaha Sac Iowa Joseph Paul McCollum Heather Lee Husman Signed
2203 2024-05-06 12:44 Anonymous (not verified) 94.188.207.228 Cma landimprovments Limited Liability Company 530 50th pleasantville 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. 2024-05-06 Cody authier cauthier85@gmail.com Pleasantville Marion Iowa Melissa authier Valerie vanhelten Signed (1) The employer does not elect the employers’ liability coverage. Cody authier cauthier85@gmail.com Self Pleasantville Marion Iowa Melissa authier Valerie vanhelten Signed
2204 2024-05-06 18:56 Anonymous (not verified) 94.188.205.168 Jim saukko Proprietorship 13232 nw 30 th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-05 Jim Saukko saukkogt500@gmail.com Polk city IA United States Dawn brown Kirk moser Signed (1) The employer does not elect the employers’ liability coverage. Jim Saukko saukkogt500@gmail.com Self Polk city IA IA Dawn brown Kirk moser Signed
2206 2024-05-07 09:10 Anonymous (not verified) 94.188.205.166 Stephanie Farmer Proprietorship 600 6th Ave, Marion, IA 52302 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. 2024-05-07 Stephanie Farmer farmer.stephanie22@gmail.com Marion Linn IA Chris Farmer Deb Hartz Signed (1) The employer does not elect the employers’ liability coverage. Stephanie Farmer farmer.stephanie22@gmail.com Self Marion Linn IA Chris Farmer Deb Hartz Signed
2209 2024-05-07 15:03 Anonymous (not verified) 94.188.207.225 THE FURNITURE GIRL LLC Limited Liability Company 19257 CONIFER LN COUNCIL BLUFFS, IA 51503 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. 2024-05-07 PATTI WIGGINS pwiggins@npdodge.com VILLISCA MONTGOMERY IA NATHAN HULL JESSICA GARDNER Signed (1) The employer does not elect the employers’ liability coverage. PATTI WIGGINS pwiggins@npdodge.com SELF VILLISCA MONTGOMERY IA NATHAN HULL JESSICA GARDNER Signed
2215 2024-05-08 22:07 Anonymous (not verified) 94.188.207.223 Self Employed-Ryan Thornton Proprietorship 8403 Horton Ave Urbandale IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-08 Ryan M Thornton rt6366155@gmail.com Urbandale Polk Iowa April Oxendale Bruce Thornton Signed (1) The employer does not elect the employers’ liability coverage. Ryan Thornton rt6366155@gmail.com Self Urbandale Polk Iowa April Oxendale Bruce Thornton Signed
2218 2024-05-09 16:20 Anonymous (not verified) 94.188.205.167 Brenda Riseley Proprietorship 2265 Copper Wynd Drive, Pleasant Hill Iowa 50327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-09 Brenda Riseley riseleybrenda@gmail.com Pleasant Hill IA United States Brenda Riseley Brenda Riseley Signed (1) The employer does not elect the employers’ liability coverage. Brenda Riseley riseleybrenda@gmail.com Self Pleasant Hill IA United States David Bottino Aubrey Stith Signed
2224 2024-05-15 11:22 Anonymous (not verified) 94.188.207.224 Community Centered Counseling Services, LLC Limited Liability Company 2711 W 63rd St Ste 3 Davenport, IA 52806 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. 2024-04-26 Adam Vilmont avilmont@cccs.me Davenport Scott Iowa Briane Franks Amanda Tesch Signed (1) The employer does not elect the employers’ liability coverage. Adam Vilmont avilmont@cccs.me Self Davenport Scott Iowa Briane Franks Amanda Tesch Signed
2226 2024-05-16 09:35 Anonymous (not verified) 94.188.207.226 Paradigm, LLC Limited Liability Company 1897 Rose Ave, Panora, IA 50216 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. 2024-05-16 Kane Powell supernovakane@gmail.com Panora Guthrie Iowa Robert Carr Sheri Meinecke Signed (1) The employer does not elect the employers’ liability coverage. Kane Powell supernovakane@gmail.com Self Panora Guthrie Iowa Robert Carr Sheri Meinecke Signed
2227 2024-05-16 11:05 Anonymous (not verified) 94.188.207.227 Ver Steegh Building Proprietorship 1660 305th St, Eddyville, IA 52553 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 Robert Scott Ver Steegh rsversteegh@gmail.com Eddyville Mahaska Iowa Brad Terpstra Robert Hallman Signed (1) The employer does not elect the employers’ liability coverage. Robert Scott Ver Steegh rsversteegh@gmail.com Self Eddyville Mahaska Iowa Brad Terpstra Robert Hallman Signed
2228 2024-05-16 11:10 Anonymous (not verified) 94.188.207.224 Gosselink Builders Limited Liability Company 910 197th Place, Pella, IA 50219 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 Dean Dingeman deanding2014@gmail.com Pella Marion Iowa Brad Terpstra Robert Hallman Signed (1) The employer does not elect the employers’ liability coverage. Dean Dingeman deanding2014@gmail.com Self Pella Marion Iowa Brad Terpstra Robert Hallman Signed
2229 2024-05-16 11:12 Anonymous (not verified) 94.188.207.227 PRISCILLA E. MBU Proprietorship 155 PRAIRIE BLUFF DR, WAUKEE, IOWA 50263 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. 2024-05-16 PRISCILLA E. MBU herturnon@gmail.com WAUKEE DALLAS IOWA JUDITH WINGO SPENCER JOHNSON Signed (1) The employer does not elect the employers’ liability coverage. PRISCILLA E. MBU herturnon@gmail.com SELF WAUKEE DALLAS IOWA WINGO SPENCER JOHNSON Signed
2232 2024-05-20 15:36 Anonymous (not verified) 94.188.207.224 Kelly Rizer Proprietorship 21090 Smit Rd Morrison Illinois 61270 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. 2024-05-20 Kelly Rizer kelbox313@gmail.com MORRISON Illinois United States Timothy Strong Theresia Burman Signed (1) The employer does not elect the employers’ liability coverage. Kelly Jo Rizer kelbox313@gmail.com Self Morrison Illinois United States Timothy Strong Theresia Burman Signed
1554 2023-04-04 16:30 Anonymous (not verified) 94.188.205.176 House of Bean Studios Limited Liability Company 2066 170th Street, Guthrie Center, IA 50115 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-04 Nicole Jazzmin Bean nicolebean.studios@gmail.com Guthrie Center Guthrie Iowa Daniel Bean Anthony Durst Signed (1) The employer does not elect the employers’ liability coverage. Nicole Jazzmin Bean houseofbeanstudios@gmail.com Self (Sole-proprietor LLC) Guthrie Center Guthrie Iowa Daniel Bean Anthony Durst Signed
2180 2024-04-25 14:19 Anonymous (not verified) 94.188.205.169 Stems Flower Shop, LLC Limited Liability Company 515 8th St SE 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 Stephanie Groom stephanie.groom@stemsiowa.com Altoona Polk Iowa Kelli Kerton Tyler Ingle Signed (1) The employer does not elect the employers’ liability coverage. Stephanie Groom stephanie.groom@stemsiowa.com Self - Business Owner Altoona Polk Iowa Kelli Kerton Tyler Ingle Signed
1786 2023-08-07 05:08 Anonymous (not verified) 94.188.205.169 Ph Construction Limited Liability Company Limited Liability Company 2643 Beaver Ave Suite 105 Des Moines Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-07 Patricia Ann Hook patricia.diverseconstruction@gmail.com Des Moines United States United States Allen W Butts Kate Ridge Signed (1) The employer does not elect the employers’ liability coverage. Patricia Ann Hook patricia.diverseconstruction@gmail.com Self - Owner Des Moines United States Iowa Allen W Butts Kate Ridge Signed
234 2020-08-18 09:13 Anonymous (not verified) 67.55.224.208 Anthony Keahi dba Hawaiian Handyman Proprietorship 928 8th Ave SE, Sioux Center, IA 51250-2502 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. 2020-08-17 Anthony Keahi hhkeahi@gmail.com Sioux Center Sioux Iowa Kyle Blankers Julia Huisman Signed (1) The employer does not elect the employers’ liability coverage. Anthony Keahi hhkeahi@gmail.com Self - sole proprietorship Sioux Center Sioux Iowa Kyle Blankers Julia Huisman Signed
1597 2023-04-24 16:03 Anonymous (not verified) 94.188.207.224 4 Iowa Construction LLC Limited Liability Company 1750 Lyon St Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-24 Luis E Cancino Mireles luiscancino55@gmail.com Des Moines Polk Iowa Jon Buller Terry Miles Signed (1) The employer does not elect the employers’ liability coverage. Luis E Cancino Mireles luiscancino55@gmail.com self / 100% owner / manager of the LLC Des Moines Polk Iowa Jon Buller Terry Miles Signed
1288 2022-08-30 16:23 Anonymous (not verified) 50.83.35.94 Black Rock Flooring LLC Limited Liability Company 189 9th st. Marion,Ia 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-30 Keith Douglas Luye Sr. Blackrockflooriing@gmail.com Marion Linn Iowa Cari Beth Lamb Daniel Ray Lamb Signed (1) The employer does not elect the employers’ liability coverage. Keith Douglas Luye Sr. Blackrockflooring@gmail.com self / my own authorized agent Marion Linn Iowa Cari Beth Lamb Daniel Ray Lamb Signed
1762 2023-07-26 12:42 Anonymous (not verified) 94.188.207.230 Down Home Decor, Inc Proprietorship 1021 2nd Ave SE Ste 200 - Dyersville, IA 52040 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-26 Vicki Knipper jheims@english-insurance.com Dyersville IA IA Joyce Heims Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Joyce Heims jheims@english-insurance.com self agent Dyersville IA IA Joyce Heims Derrick Parsons Signed
1763 2023-07-26 12:46 Anonymous (not verified) 94.188.207.224 Down Home Decor Inc Proprietorship 1021 2nd Ave SE Ste 200 - Dyersville, IA 52040 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-26 Steve Knipper jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Joyce Heims jheims@english-insurance.com self agent Dyersville IA IA Joyce Heims Derrick Parsons Signed
155 2020-05-12 17:03 Anonymous (not verified) 173.17.184.241 Shelly Whalen Proprietorship 1625 Darby Dr Waterloo IA 50702 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. 2020-05-12 Shelly Whalen swhalen90@hotmail.com Waterloo IA United States Taylor Whalen Todd Gerleman Signed (1) The employer does not elect the employers’ liability coverage. Shelly Whalen swhalen90@hotmail.com self employed Waterloo IA United States Taylor Whalen Todd Gerleman Signed
254 2020-09-10 20:13 Anonymous (not verified) 97.127.219.61 Scott Woodward Proprietorship 2619 west 69th St. davenport Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-10 Scott Woodward woodwardscott2001@gmail.com Davenport Scott Iowa Scott Woodward Scott Woodward Signed (1) The employer does not elect the employers’ liability coverage. Scott Woodward woodwardscott2001@gmail.com Self employed Davenport Scott Iowa Scott Woodward Scott Woodward Signed
680 2021-10-18 13:58 Anonymous (not verified) 166.181.86.88 Gerald Jerome Proprietorship 2668 Wapsi Ridge Dr. Walker, IA 52352 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-18 Gerald Jerome geraldjerome373@ymail.com Walker IA United States Benjamin J Barkalow James M. Barkalow Signed (1) The employer does not elect the employers’ liability coverage. Gerald Jerome geraldjerome373@ymail.com Self employed Walker Linn Iowa Benjamin J Barkalow James M Barkalow Signed
716 2021-11-05 13:22 Anonymous (not verified) 209.252.172.87 Rick Clifford Clifford Custom Tile & Flooring Proprietorship 1563 Palmer Ct NE, 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. 2020-09-24 Rick Clifford cliffordcustomtile@gmail.com Solon Johnson Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Rick Clifford Clifford Custom Tile & Flooring cliffordcustomtile@gmail.com Self Employed Solon Johnson Iowa Sarah Coberley Heather Howell Signed