207 |
2020-07-16 13:05 |
Anonymous (not verified) |
173.16.140.254 |
Steve Kennedy |
Proprietorship |
5108 SW 13th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Steve Kennedy |
stevekennedy@gmail.com |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Kennedy |
stevekennedy007@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
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 |
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 |
966 |
2022-03-11 10:04 |
Anonymous (not verified) |
173.19.189.168 |
Steger Siding & Construction |
Limited Liability Company |
1020 25th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-11 |
Jared Steger |
jared.steger@gmail.com |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Steger |
jared.steger@gmail.com |
self |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
1730 |
2023-07-09 23:39 |
Anonymous (not verified) |
94.188.207.225 |
Steffens Constuction |
Proprietorship |
68222 Lansing Road, Wiota, IA 50274 |
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 |
Bradyn Richard Steffens |
steffens4211@gmail.com |
Wiota |
Cass |
Iowa |
Katrina Sonntag |
Chris Obrien |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Audra Kelley Steffens |
steffens4211@gmail.com |
wife |
Wiota |
Cass |
Iowa |
Katrina Sonntag |
Chris Obrien |
Signed |
889 |
2022-02-03 14:52 |
Anonymous (not verified) |
207.177.96.173 |
Stecker Rentals Inc. |
Limited Liability Company |
1439 Kate Shelley Dr. Boone 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. |
2022-02-03 |
Holly Stecker |
hollystecker6@gmail.com |
Boone |
Boone |
IA |
Shana Mallas |
Laura Hutchcroft |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Holly Stecker |
hollystecker6@gmail.com |
Owner |
Boone |
Boone |
IA |
Shana Mallas |
Laura Hutchcroft |
Signed |
488 |
2021-04-20 13:42 |
Anonymous (not verified) |
69.63.16.2 |
STC Construction LLC |
Limited Liability Company |
329 Sycamore 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. |
2021-04-20 |
Sean Crane |
stc0241@gmail.com |
Riverside |
Washington |
Iowa |
Carol Glass |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Crane |
stc0241@gmail.com |
Managing Member |
Riverside |
Washingon |
Iowa |
Carol Glass |
Dyan Kriener |
Signed |
1417 |
2023-01-11 08:55 |
Anonymous (not verified) |
174.235.209.245 |
Standard Insulation Company, LLC |
Limited Liability Company |
1066 Prairieview Ave., Van Meter, IA 50261 |
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. |
2023-01-11 |
Mitchell Simonson |
standard.insulation@outlook.com |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Simonson |
standard.insulation@outlook.com |
Owner |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
926 |
2022-02-17 15:20 |
Anonymous (not verified) |
166.181.83.68 |
Staley Trucking LLC |
Limited Liability Company |
1388 140th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Travis Staley |
staleyracing121@gmail.com |
Hampton |
Franklin |
IA |
Tyler Staley |
Jeff Staley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Staley |
staleyracing121@gmail.com |
President |
Hampton |
Franklin |
IA |
Tyler Staley |
Jeff Staley |
Signed |
1570 |
2023-04-12 18:09 |
Anonymous (not verified) |
94.188.205.166 |
Staley Engineering Consultants, LLC |
Limited Liability Company |
4212 Holland Drive, 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. |
2023-04-12 |
Donald K Staley |
Don.Staley@q.com |
Des Moines |
Iowa |
United States |
Kendall S. Staley |
Gary D. Hlavka |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Donald K Staley |
Don.Staley@q.com |
Owner |
Des Moines |
Iowa |
United States |
Kendall S. Staley |
Gary D. Hlavka |
Signed |
765 |
2021-11-22 16:07 |
Anonymous (not verified) |
63.229.189.35 |
Stahmer Construction |
Proprietorship |
318 Jackson St N Harris IA 51345 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Alan Stahmer |
abigail@rickmilesartisans.com |
Harris |
Osceola |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alan Stahmer |
abigail@rickmilesartisans.com |
Self |
Harris |
Osceola |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
728 |
2021-11-05 14:52 |
Anonymous (not verified) |
209.252.172.87 |
Stacy Wade Wade Flooring Specialist |
Proprietorship |
2481 247th St, Washington, IA 52353 |
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. |
2020-09-15 |
Stacy Wade |
stacywade92@gmail.com |
Washington |
Washington |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Wade |
stacywade92@gmail.com |
Self |
Washington |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1654 |
2023-05-19 11:09 |
Anonymous (not verified) |
94.188.205.176 |
ST SULLIVAN CONSTRUCTION COMPANY |
Proprietorship |
1614 100TH ST., OELWEIN, IOWA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-19 |
STEVE SULLIVAN |
sullycon@msn.com |
Oelwein |
Fayette |
Iowa |
Bobbie J Bergan |
Shelby Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
STEVE SULLIVAN |
sullycon@msn.com |
OWNER |
OELWEIN |
FAYETTE |
IOWA |
BOBBIE J BERGAN |
SHELBY WILLIAMS |
Signed |
568 |
2021-07-09 09:26 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
P.O. Box 561 Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-21 |
Jason Snow |
k.kooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
k.kooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
570 |
2021-07-09 16:42 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
P.O. Box 561 Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-21 |
Jason Snow |
kkooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
kkooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
593 |
2021-08-03 12:29 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
PO Box 561, Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-21 |
Jason Snow |
k.kooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
k.kooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
564 |
2021-07-08 13:33 |
Anonymous (not verified) |
173.31.156.49 |
SS Docks |
Limited Liability Company |
P.O. Box 561 Okoboji IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-07-08 |
Jason Andrew Snow |
snowjas75@gmail.com |
Lake Park |
Dickinson |
IA |
Amber Egesdal |
Vickie Walters |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
SS Docks |
snowjas75@gmail.com |
Owner |
Okoboji |
Dickinson |
IA |
Amber Egesdal |
Vickie Walters |
Signed |
1696 |
2023-06-19 09:11 |
Anonymous (not verified) |
94.188.205.174 |
Spruce Cleaning Co |
Proprietorship |
2302 Cedar Street Granger, Iowa 50109 |
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. |
2023-06-19 |
Sarah Champion |
Sprucecleaningcodsm@gmail.com |
Granger |
Dallas |
Iowa |
Amy Greek |
Noah Bassett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Champion |
Sprucecleaningcodsm@gmail.com |
Employer |
Granger |
Dallas |
Iowa |
Amy Greek |
Noah Bassett |
Signed |
1387 |
2022-12-10 22:39 |
Anonymous (not verified) |
98.156.163.144 |
Springfield Staffing Solution |
Limited Liability Company |
14918 Tuff Rd, Manor TX 78653 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-10 |
Beluchukwu Ebede |
admin@springfield-staffing.com |
Manor |
Travis |
United States |
Oluchukwu Nwokoye |
Beluchukwu Ebede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beluchukwu Ebede |
admin@springfield-staffing.com |
Self |
Manor |
Travis |
United States |
Oluchukwu Nwokoye |
Beluchukwu Ebede |
Signed |
1388 |
2022-12-10 22:42 |
Anonymous (not verified) |
98.156.163.144 |
Springfield Staffing Solution |
Limited Liability Company |
14918 Tuff Rd, Manor TX 78653 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-10 |
Oluchukwu Nwokoye |
oly@springfieldstaffing.com |
Manor |
Travis |
United States |
Beluchukwu R Ebede |
Oluchukwu Nwokoye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beluchukwu Ebede |
admin@springfield-staffing.com |
Partner |
Manor |
Travis |
United States |
Beluchukwu R Ebede |
Oluchukwu Nwokoye |
Signed |
1349 |
2022-10-28 12:37 |
Anonymous (not verified) |
173.26.153.59 |
spotlight drywall |
Proprietorship |
1001 7th st. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-01 |
paul woods |
spotlight.2008@hotmail.com |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
thuy do |
spotlight.2008@hotmail.com |
bookeeper |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |
1100 |
2022-05-13 12:54 |
Anonymous (not verified) |
50.83.96.157 |
Spindrift LLC |
Limited Liability Company |
2825 Newport Rd NE Iowa City IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-13 |
Nathaniel James Dooley |
spindriftlawnandsnow@gmail.com |
Iowa City |
Johnson |
Iowa |
Sharon Dooley |
Kristen Simpson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathaniel James Dooley |
spindriftlawnandsnow@gmail.com |
Same |
Iowa City |
Johnson |
Iowa |
Sharon Dooley |
Kristen Simpson |
Signed |
1445 |
2023-02-08 14:56 |
Anonymous (not verified) |
94.188.207.225 |
Spencer Imaging Center, LLC |
Limited Liability Company |
710 S. Grand Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-08 |
William Jay Muller |
mullerwilliam@hotmail.com |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad A Roemeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alexander Pruitt |
apruitt@ncn.net |
Partner |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad A Roemeling |
Signed |
1454 |
2023-02-14 09:34 |
Anonymous (not verified) |
94.188.207.227 |
Spencer Imaging Center, LLC |
Limited Liability Company |
710 S. Grand Ave., Spencer, IA 51301 |
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. |
2023-02-14 |
Alexander Pruitt |
apruitt@ncn.net |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad Roemeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Muller |
mullerwilliam@hotmail.com |
Co owner |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad Roemeling |
Signed |
1351 |
2022-10-31 16:36 |
Anonymous (not verified) |
75.231.74.186 |
Spencer C Nash LLC |
Limited Liability Company |
4233 Pineview Dr NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
Spencer Nash |
spencer@optionsexteriors.com |
Cedar Rapids |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Nash |
spencer@optionsexteriors.com |
Owner/Self |
Cedar Rapids |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
1995 |
2024-01-23 15:08 |
Anonymous (not verified) |
94.188.205.167 |
Spencer Abbott |
Proprietorship |
1358 170th Ave, Murray Iowa 50174 |
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. |
2024-01-23 |
Spencer Abbott |
sabbott1800@gmail.com |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Abbott |
sabbott1800@gmail.com |
sole proprietor |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
1578 |
2023-04-17 15:33 |
Anonymous (not verified) |
94.188.205.174 |
Spark Train Express LLC |
Limited Liability Company |
16877 500th St, Pocahontas, IA 50574 |
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. |
2023-04-17 |
Austin Sparks |
sparksaustin.11@gmail.com |
Pocahontas |
Pocahontas |
Iowa |
Stephanie Webbink |
Christian Lynch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Sparks |
sparksaustin.11@gmail.com |
Owner |
Pocahontas |
Pocahontas |
Iowa |
Stephanie Webbink |
Christian Lynch |
Signed |
1141 |
2022-06-03 08:15 |
Anonymous (not verified) |
173.23.251.188 |
SP Exteriors, LLC |
Limited Liability Company |
804 Philip St Des Moines, IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-03 |
Travis Espey |
tespey48@gmail.com |
Des Moines |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Espey |
tespey48@gmail.com |
owner |
Des Moines |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
519 |
2021-05-13 10:32 |
Anonymous (not verified) |
50.82.22.159 |
Southern Iowa Crane, Incorporated |
Proprietorship |
635 Mill Street; Ottumwa, IA 52501 |
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. |
2021-05-13 |
Steve Lee |
southerniowacraneinc@hotmail.com |
Ottumwa |
Wapello |
Iowa |
Brandon Gravett |
Sarah Gravett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Lee |
sotherniowacraneinc@hotmail.com |
Self |
Ottumwa |
Wapello |
Iowa |
Sarah Gravett |
Brandon Gravett |
Signed |
238 |
2020-08-19 13:13 |
Anonymous (not verified) |
107.77.199.95 |
Southern Ag Care |
Limited Liability Company |
301 Hoover Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-19 |
Southern Ag Care |
russ_buntyn@yahoo.com |
Monroe |
Ouachita |
LA |
Mark Buntyn |
Johna Buntyn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Russell Buntyn |
russ_buntyn@yahoo.com |
Owner |
Monroe |
Ouachita |
LA |
Mark Buntyn |
Johna Buntyn |
Signed |
2132 |
2024-04-03 19:49 |
Anonymous (not verified) |
94.188.205.166 |
Soto Stone LLC |
Limited Liability Partnership |
1071 mansfield 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-04-03 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
self |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
2133 |
2024-04-03 19:58 |
Anonymous (not verified) |
94.188.207.228 |
Soto Stone LLC |
Limited Liability Company |
1071 mansfield 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-04-03 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
self |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
589 |
2021-07-28 16:09 |
Anonymous (not verified) |
97.125.35.240 |
Sotero Alonso Calderon Velasquez |
Proprietorship |
1312 Idaho 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. |
2021-07-26 |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
subcontractor |
Des MOines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
1367 |
2022-11-11 11:06 |
Anonymous (not verified) |
173.29.231.17 |
Sosa Flooring |
Proprietorship |
2310 NE 16TH Ankeny, Iowa 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-11 |
Zeferino Alcantara Sosa |
sunnysosa@aol.com |
Ankeny |
Polk |
Iowa |
Ashley Temple |
Sunny Sosa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zeferino Alcantara Sosa |
sunnysosa@aol.com |
OWNER |
Ankeny |
Polk |
Iowa |
Ashley Temple |
Sunny Sosa |
Signed |
244 |
2020-08-25 13:32 |
Anonymous (not verified) |
97.64.194.122 |
Soren Henriksen |
Proprietorship |
2165 Roosevelt St., 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. |
2020-08-20 |
Soren Henriksen |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Soren Henriksen |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
2017 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.174 |
SolQ, LLC |
Limited Liability Company |
184 N 100 E Suite A Logan UT 84321 |
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. |
2024-02-01 |
Casey Ryan Winger |
casey@solq.com |
Providence |
Cache |
UT |
Perry M. Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casey Ryan Winger |
casey@solq.com |
Owner |
Providence |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
2018 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.177 |
SolQ, LLC |
Limited Liability Company |
184 N 100 E STE A Logan, UT 84321 |
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. |
2024-02-01 |
David Bean |
dave@solq.com |
Clarkston |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Bean |
dave@solq.com |
Owner |
Logan |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
2019 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.167 |
SolQ LLC |
Limited Liability Company |
184 N 100 E STE A Logan, UT 84321 |
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. |
2024-02-01 |
wyatt phelps |
wyatt@solq.com |
Eagle Mountain |
UT |
United States |
Perry M Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
wyatt phelps |
wyatt@solq.com |
Owner |
Eagle Mountain |
UT |
United States |
Perry M Koker |
Rebecca Koger |
Signed |
945 |
2022-03-04 10:15 |
Anonymous (not verified) |
97.125.39.88 |
Solid Solutions Caulking LLC. |
Limited Liability Company |
1011 N. Ankeny Blvd P.O. Box 216. Ankeny Ia. 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-04 |
Jesse Guilford |
sscaulking@yahoo.com |
Ankeny |
Polk |
Iowa |
Jesse Guilford |
Jade Guilford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jade Guilford |
sscaulking@yahoo.com |
Secratary |
Ankeny |
Polk |
Iowa |
Jesse Guilford |
Jade Guilford |
Signed |
1419 |
2023-01-12 09:27 |
Anonymous (not verified) |
71.34.173.44 |
Solid Solutions Caulking LLC. |
Limited Liability Company |
1011 N. Ankeny BLVD Po Box 216 Ankeny IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Jesse Guilford |
sscaulking@yahoo.com |
Ankeny |
Polk |
Iowa |
Jesse Guilford |
Jade Guilford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Guilford |
sscaulking@yahoo.com |
Self |
Ankeny |
Polk |
Iowa |
Jesse Guilford |
Jade Guilford |
Signed |
2072 |
2024-03-01 11:27 |
Anonymous (not verified) |
94.188.207.226 |
SoldFast Real Estate L.L.C. |
Limited Liability Company |
5525 Meredith Drive 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. |
2024-03-02 |
Darlyn Fructuoso |
thejjscleaningllc@gmail.com |
Des Moines |
Polk |
IA |
Beatriz Musselman |
Darlyn Fructuoso |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Wilkinson |
cody@soldfast.com |
Contractor |
Des Moine |
Polk |
IA |
Beatriz Musselman |
Darlyn Fructuoso |
Signed |
94 |
2020-03-18 13:18 |
Anonymous (not verified) |
174.243.114.80 |
Sogard Excavating |
Limited Liability Company |
2374 380th St, Jewell, IA 50130 |
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. |
2020-03-18 |
Jon A Sogard |
jsogard22@gmail.com |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sogard Excavating LLC |
jsogard22@gmail.com |
owner |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
118 |
2020-04-13 11:48 |
Anonymous (not verified) |
173.26.152.222 |
Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
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. |
2020-04-14 |
Joseph D. Sobczyk |
joczyk@aol.com |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
121 |
2020-04-14 15:11 |
Anonymous (not verified) |
173.31.176.75 |
Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
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. |
2020-04-14 |
Michele E Collison |
darmstad48@aol.com |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
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 |
1908 |
2023-11-15 10:59 |
Anonymous (not verified) |
94.188.207.230 |
Snelling Construction, LLC |
Limited Liability Company |
309 Railroad Ave. Tripoli, IA 50676 |
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. |
2023-11-15 |
Spencer W. Snelling |
ssnell71@yahoo.com |
Tripoili |
Bremer |
Iowa |
Michael Meyer |
Shawn Pipho |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer W. Snelling |
ssnell71@yahoo.com |
same |
Tripoli |
Bremer |
Iowa |
Michael Meyer |
Shawn Pipho |
Signed |
1643 |
2023-05-12 07:56 |
Anonymous (not verified) |
94.188.205.169 |
Smooth Finish Drywall |
Proprietorship |
3111 115th Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
Seth T Mize II |
stmize@hotmail.com |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth T Mize II |
stmize@hotmail.com |
Self |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
91 |
2020-03-13 15:51 |
Anonymous (not verified) |
173.24.190.134 |
Small Town RV, LLC |
Limited Liability Company |
112 Miller Street |
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. |
2020-03-09 |
Heath Sabin |
sales@smalltownrv.com |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Sabin |
sales@smalltownrv.com |
Member of LLC |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
2020 |
2024-02-02 07:14 |
Anonymous (not verified) |
94.188.207.230 |
SM4 Consulting LLC |
Limited Liability Company |
503 E 6TH 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. |
2024-02-02 |
Chad Smith |
sm4consultingllc@gmail.com |
PRAIRIE CITY |
Jasper |
Iowa |
Nicole Smith |
Maybelle Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Smith |
sm4consultingllc@gmail.com |
self |
PRAIRIE CITY |
Jasper |
Iowa |
Nicole Smith |
Maybelle Smith |
Signed |
111 |
2020-04-06 16:04 |
Anonymous (not verified) |
209.152.124.33 |
SM Tile Design LLC |
Limited Liability Company |
670 Daybreak Drive |
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. |
2020-04-06 |
Samir Mulalic |
Smtiledesign@gmail.com |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samir Mulalic |
Smtiledesign@gmail.com |
Same |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |