Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 251 - 300 of 2215. Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.

#	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:
537	2021-06-07 15:25	Anonymous (not verified)	66.188.136.150	Casey Young	Proprietorship	10731 State Highway 118 Turrell, AR 72384	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.	2021-06-03	Casey Young	kschumacher@tricorinsurance.com	Turrell	Crittenden	AR	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Casey Young	kschumacher@tricorinsurance.com	Same	Turrell	Crittenden	AR	Mitch Kemp	Shuree Behr	Signed
845	2022-01-20 09:06	Anonymous (not verified)	208.126.69.10	KenX Pest Control	Limited Liability Company	350 2nd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-20	Ken YARRINGTON	kenxpestcontrol@hotmail.com	Truro	IA	IA	James Gage	Kent Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Kenneth Charles Yarrington	kenxpestcontrol@hotmal.com	Myself	Truro	IA	IA	James Gage	Kent Smith	Signed
1467	2023-02-17 16:14	Anonymous (not verified)	94.188.205.169	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	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.	2023-02-17	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	H & C Construction	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed
1508	2023-03-09 10:34	Anonymous (not verified)	94.188.205.176	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Charles Clarke	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed
454	2021-03-26 09:46	Anonymous (not verified)	50.82.130.211	Jason Thoren	Proprietorship	104 1st Street NW, 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.	2021-03-04	Jason Thoren	cmins_re@mchsi.com	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Thoren	cmins_re@mchsi.com	Self	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	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
1915	2023-11-21 04:06	Anonymous (not verified)	94.188.207.225	Advanced Foam Systems	Limited Liability Company	1378 Midway 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.	2023-11-18	Randy Block	advancedfoamsystems@yahoo.com	Tripoli	Bremer	Iowa	Linda Block	Brady Block	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy Block	advancedfoamsystems@yahoo.com	Me	Tripoli	Bremer	Iowa	Linda block	Brady block	Signed
2212	2024-05-08 13:26	Anonymous (not verified)	94.188.207.224	Lifetime Roofing Installations, LLC	Limited Liability Company	703 2nd St. SW 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.	2024-05-08	Kurtis Walvatne	lifetimeroofing12@yahoo.com	Tripoli	Bremer	Iowa	Mike Meyer	Kelly Walvatne	Signed	(1) The employer does not elect the employers’ liability coverage.	Kurtis Walvatne	lifetimeroofing12@yahoo.com	Owner	Tripoli	Bremer	Iowa	Mike Meyer	Kelly Walvatne	Signed
377	2021-01-26 13:31	Anonymous (not verified)	184.63.6.1	Matt Reynolds	Proprietorship	684 Cedar Valley Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-26	Matt Reynolds	matt.reynolds0891@gmail.com	Tipton	Cedar	Iowa	Anna Miller	Steve Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Reynolds	matt.reynolds0891@gmail.com	Proprietorship	Tipton	Cedar	Iowa	Anna Miller	Steve Miller	Signed
718	2021-11-05 13:41	Anonymous (not verified)	209.252.172.87	Wayne Hunt	Proprietorship	405 E 4th St Tipton, Ia 52772	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.	2020-04-12	Wayne Hunt	installation@bachmeiercarpetone.com	Tipton	Cedar	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Hunt	installation@bachmeiercarpetone.com	Self	Tipton	Cedar	Iowa	Sarah Coberley	Heather Howell	Signed
913	2022-02-14 18:50	Anonymous (not verified)	72.25.23.147	Teimer Trucking	Limited Liability Company	3277 102nd St. Durant, IA 52747	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.	2022-02-14	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Cedar	Iowa	Barry Boll	Jennifer Treimer	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Owner	Tipton	Cedar	Iowa	Barry Boll	Jennifer Treimer	Signed
1484	2023-02-25 16:42	Anonymous (not verified)	94.188.205.177	Carpenter wood shed/ rays longging	Limited Liability Company	1631 230th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-27	Raymond Carpenter	corinnafrymoyer@gmail.com	tipton	Cedar	Iowa	corinna frymoyer	Levi carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Carpenter	corinnafrymoyer@gmail.com	Self	Tipton	Cedar	Iowa	Corinna frymoyer	Levi carpenter	Signed
1803	2023-08-15 19:03	Anonymous (not verified)	94.188.207.224	Teimer Trucking LLC	Limited Liability Company	3277 102nd St. Durant, IA 52747-9524	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.	2023-08-15	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Iowa	United States	Spencer Lea Parsons	Sydney Rae Lane	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Self	Tipton	Iowa	United States	Spencer Lea Parsons	Sydney Rae Lane	Signed
1808	2023-08-17 17:17	Anonymous (not verified)	94.188.205.168	Treimer Trucking LLC	Limited Liability Company	3277 102nd St. Durant, IA 52747-9524	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.	2023-08-17	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Iowa	United States	Sydney Rae Lane	Spencer Lea Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Self	Tipton	Iowa	United States	Syndey Rae Lane	Spencer Lea Parsons	Signed
60	2020-02-12 10:10	Anonymous (not verified)	198.167.182.164	Sara Torres	Proprietorship	419 Lilac St, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-11	Sara Torres	skb_blue08@hotmail.com	Tiffin	Johnson	Iowa	Steven J Fishman	E. Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sara Torres	skb_blue08@hotmail.com	Owner	Tiffin	Johnson	Iowa	Steven J Fishman	E Dyan Kriener	Signed
151	2020-05-07 15:57	Anonymous (not verified)	198.167.182.164	Hawk-I Trucking LLC	Limited Liability Company	521 Greenfield Dr, Tiffin, IA 52340	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.	2020-05-06	Chad Lee Freeman	ricenogle@southslope.net	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Lee Freeman	ricenogle@southslope.net	Managing Member	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	Signed
505	2021-05-10 07:06	Anonymous (not verified)	69.63.16.2	Three Boys Contracting LLC	Limited Liability Company	1108 Cullen Dr, Tiffin, IA 52340	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.	2021-05-08	Brandon J Campbell	threeboyscarpentry@gmail.com	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon J Campbell	threeboyscarpentry@gmail.com	Managing Member	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed
949	2022-03-04 16:09	Anonymous (not verified)	173.20.147.171	Duwa Waterproofing LLC	Limited Liability Company	729 Deer view Ave, Tiffin, IA 52340	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	Stacy Duwa	duwawaterproofing@gmail.com	Tiffin	Johnson	Iowa	Lauren Obermann	Don Vittetoe	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	owner	Tiffin	Johnson	Iowa	Lauren Obermann	Don Vittetoe	Signed
954	2022-03-08 11:07	Anonymous (not verified)	174.192.138.191	Duwa Waterproofing	Limited Liability Company	729 Deer View Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-08	Stacy Duwa	duwawaterproofing@gmail.com	Tiffin	Johnson	Iowa	Chad Cooper	Curtis Sexton	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	President	Tiffin	Johnson	Iowa	Chad Cooper	Curtis Sexton	Signed
1080	2022-04-29 08:59	Anonymous (not verified)	216.51.225.18	Lee's Haul It & Property Care	Proprietorship	212 Village Dr #5, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-29	Tim Lee	timclee160@gmail.com	Tiffin	Johnson	Iowa	Lee Krueger	Aaron Oehring	Signed	(1) The employer does not elect the employers’ liability coverage.	Lee's Haul It & Property Care	leeshaulit@gmail.com	Owner	Tiffin	Johnson	Iowa	Tim Lee	Aaron Oehring	Signed
1316	2022-09-21 14:49	Anonymous (not verified)	184.81.198.17	Ellen Faye Stevenson	Proprietorship	201 Stephans st. Tiffin, Iowa 52340	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.	2022-09-21	Ellen Faye Stevenson	nelle@southslope.net	Tiffin	Johnson	Iowa	Catherine Louise Nelson	Joseph Roger Titone	Signed	(1) The employer does not elect the employers’ liability coverage.	Ellen Faye Stevenson	nelle@southslope.net	myself	Tiffin	Johnson	Iowa	Catherine Louise Nelson	Joseph Roger Titone	Signed
1699	2023-06-22 07:36	Anonymous (not verified)	94.188.205.175	V2E Advisors LLC	Limited Liability Company	701 Lakeview Ct, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Tyler Rhamy	trhamy@v2eadvisors.com	Tiffin	Iowa	United States	Tasha Rhamy	Tom Rhamy	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Rhamy	trhamy@v2eadvisors.com	Member / President	Tiffin	Johnson	Iowa	Tom Rhamy	Tasha Rhamy	Signed
1951	2023-12-12 13:10	Anonymous (not verified)	94.188.207.230	Patrick McGuinnis	Limited Liability Company	5697 Squire Circle, Thomson, IL 61285	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-09	Patrick A McGinnis	McGinnistrucking2023@yahoo.com	Thomson	Carroll	IL	Ashleigh McGuinnis	Kimberly Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Parick A McGunnis	mcginnistrucking2023@yahoo.com	Self	Thomson	Carroll	IL	Ashleigh McGinnis	Kimberly Williams	Signed
712	2021-11-05 10:38	Anonymous (not verified)	64.5.73.247	Glenn Langel	Proprietorship	20581 300th St, Templeton, IA 51463	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.	2021-10-29	Glenn Langel	gklangel@netins.net	Templeton	Carroll	Iowa	Jonathan Heydon	Mitchell Langel	Signed	(1) The employer does not elect the employers’ liability coverage.	Glenn Langel	gklangel@netins.net	Owner	Templeton	Carroll	Iowa	Jonathan Heydon	Mitchell Langel	Signed
713	2021-11-05 10:41	Anonymous (not verified)	64.5.73.247	Mitchell Langel	Proprietorship	20581 300th St, Templeton IA 51463	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.	2021-10-29	Mitchell Langel	gklangel@netins.net	Templeton	Carroll	Iowa	Jonathan Heydon	Lacey Marsh	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Langel	gklangel@netins.net	Owner	Templeton	Carroll	Iowa	Jonathan Heydon	Lacey Marsh	Signed
1447	2023-02-09 16:12	Anonymous (not verified)	94.188.205.166	Ryan Klocke	Limited Liability Company	315 1st Street Templeton, IA 54163	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.	2022-02-09	Ryan Klocke	heidi@nextgenagsupply.com	Templeton	Carroll	Iowa	Kim Gienau	Zach Counsell	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Klocke	heidi@nexgenagsupply.com	President	Templeton	Carroll	Iowa	Kim Gienau	Zach Counsell	Signed
469	2021-04-12 16:49	Anonymous (not verified)	65.103.82.36	Stice Construction	Proprietorship	13723 140th st W	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-07-22	Alex Stice	Astice17@hotmail.com	Taylor Ridge	Rock Island	IL	Ashley Stice	JIm Stice	Signed	(1) The employer does not elect the employers’ liability coverage.	Alex Stice	astice17@hotmail.com	self	taylor ridge	rock island	il	Ashley stice	Jim Stice	Signed
315	2020-11-13 10:48	Anonymous (not verified)	66.188.136.150	Jessie Spurlin	Proprietorship	58977 Al Hwy 77, Talladega, AL 35160	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.	2020-11-11	Jessie Spurlin	kschumacher@tricorinsurance.com	Talladega	Talladega	AL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessie Spurlin	kschumacher@tricorinsurance.com	Same	Talledaga	Talledaga	AL	Russell Masartis	Nancy Wortley	Signed
1090	2022-05-06 08:08	Anonymous (not verified)	65.111.39.23	Farr TRucking Inc	Proprietorship	2206 E Locust Ln, Table Grove, IL 61482	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.	2022-05-06	Donald Paul Farr	howthewestisdone@gmail.com	Table Grove	Fulton	Illinois	Tamra Stambaugh	Keith Allard	Signed	(1) The employer does not elect the employers’ liability coverage.	DeYonne L Farr	howthewestisdone@gmail.com	Secretary	Table Grove	Fulton	Illinois	Tamra Stambaugh	Keith Allard	Signed
1081	2022-04-29 11:28	Anonymous (not verified)	173.18.22.217	CB's Tree & Lawn Service	Limited Liability Company	593 25th Place Swan IA 50252	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-29	Robert Beau Wittkowski	robertwittkowski1@gmail.com	Swan	Marion	Iowa	Lesa Reeves	William Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Beau Wittkowski	robertwittkowski1@gmail.com	Owner	Swan	Marion	Iowa	Lesa Reeves	William Schuldt	Signed
1537	2023-03-27 13:21	Anonymous (not verified)	94.188.207.228	miller hybrids	Limited Liability Company	1213 Larch Ave, Kalona, IA 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-01	Jeremy Wakerhauser	jwakerhauser@gmail.com	Sun Prairie	WI	United States	Jeremy Wakerhauser	Jeremy Wakerhauser	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy Wakerhauser	jwakerhauser@gmail.com	sole proprieter	Sun Prairie	WI	United States	Jeremy Wakerhauser	Jeremy Wakerhauser	Signed
1671	2023-06-01 11:17	Anonymous (not verified)	94.188.205.166	Edwin Kime	Proprietorship	2920 Windsor av sumner iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	edwin kime	edwinkime01@gmail.com	sumner	ia	United States	Lori Ann kime	Kiley Nicole kime	Signed	(1) The employer does not elect the employers’ liability coverage.	edwin kime	edwinkime01@gmail.com	Same	sumner	ia	United States	Lori Ann kime	Kiley nicolevkime	Signed
1689	2023-06-13 19:55	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, Waterloo, IA ,50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-13	Gerardo Reyes-lopez	greyeslopez9@gmail.com	Waterloo	Black Hawk	Iowa	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
1690	2023-06-13 20:01	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, Waterloo, Iowa, 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-13	Gerardo Reyes-lopez	bernardo@reyesconstruct.com	Waterloo	IA	United States	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
1847	2023-09-18 18:20	Anonymous (not verified)	94.188.205.168	William O'Brien	Proprietorship	1069 Yukon Ave Sumner Iowa 50674	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	William Charles O'Brien	wcobrien63@gmail.com	Sumner	Bremer	Iowa	Patrick B Dillon	Christina Rader	Signed	(1) The employer does not elect the employers’ liability coverage.	William Charles O'Brien	wcobrien63@gmail.com	self	Sumner	Bremer	Iowa	Patrick B Dillon	Christina Rader	Signed
2048	2024-02-16 07:42	Anonymous (not verified)	94.188.207.224	Alexandra Machedon LLC	Proprietorship	319 N Western Street Stuart, IA 50250	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.	2024-02-16	Alexandra Machedon	ali@alimachedon.com	Stuart	USA	Iowa	Jessica Cash	Vicki Collins	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexandra Machedon	ali@alimachedon.com	Self	Stuart	US	IA	Jessi Cash	Vicki Collins	Signed
2062	2024-02-29 08:25	Anonymous (not verified)	94.188.205.169	Midwest Splicing LLC	Limited Liability Company	1803 N HALF BANK RD , Stringtown , OK 74569	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-29	James Xiong	midwestsplicing71@yahoo.com	Stringtown	OKLAHOMA	OKLAHOMA	Vang Pao Chang	Xia Vang	Signed	(1) The employer does not elect the employers’ liability coverage.	James Xiong	midwestsplicing71@yahoo.com	owner	STRINGTOWN	Oklahoma	Oklahoma	xia Vang	Vang Pao Chang	Signed
255	2020-09-11 13:42	Anonymous (not verified)	173.190.65.6	A Fisk Trucking, LLC	Limited Liability Company	PO Box 332, Strawberry Point, IA 52076	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.	2020-08-14	Andrew Fisk	afisktrucking@gmail.com	Strawberry Point	Clayton	Iowa	Pamela Vaske	Crystal Thole	Signed	(1) The employer does not elect the employers’ liability coverage.	A Fisk Trucking, LLC	afisktrucking@gmail.com	Member/Manager	Strawberry Point	Clayton	Iowa	Pamela Vaske	Crystal Thole	Signed
1044	2022-04-13 09:11	Anonymous (not verified)	166.181.81.114	Paul Wall Assemblies LLC	Limited Liability Company	38165 Belgian rd.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-04-13	Paul Carnicle	paulcarnicle@yahoo.com	Strawberry Point	Iowa	United States	Alexander Gabriel Guthrie	Sebastin Thompsin	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Paul Carnicle	paulcarnicle@yahoo.com	Partner	Strawberry Point	Iowa	United States	Alexander Gabriel Guthrie	Sebastin Thompson	Signed
85	2020-03-09 08:17	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	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.	2020-03-05	Jessi Kettenacker	jessi@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessi Kettenacker	jessi@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
86	2020-03-09 08:19	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	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.	2020-03-05	Cande Coulter	cande@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Candy Coulter	cande@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
265	2020-09-21 14:41	Anonymous (not verified)	74.84.65.174	Nagol Enterprises	Limited Liability Company	16124 PLEASANT VALLEY DR	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-21	Logan Victor Ante	antelogan@gmail.com	Story CIty	Story	iowa	Brian Wade Warren	Tyler Christian Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Logan Victor Ante	antelogan@gmail.com	Same	Story CIty	IA	IA	Brian Wade Warren	Tyler Christian Thompson	Signed
787	2021-12-13 16:15	Anonymous (not verified)	64.5.77.84	Heartland Counseling Services	Limited Liability Company	813 Flindt 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.	2021-11-05	Kathleen Ruscitto	info@heartlandcounselingia.com	STORM LAKE	Iowa	United States	David Kirk	Michael Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Kathleen Ruscitto	info@heartlandcounselingia.com	Self/Owner	STORM LAKE	Iowa	United States	David Kirk	Michael Robertson	Signed
2042	2024-02-12 13:07	Anonymous (not verified)	94.188.205.175	Evelyn R Ventura Terrazas	Proprietorship	524 Terrence	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.	2024-02-12	Evelyn R Ventura Terrazas	evelynterrazas@gmail.com	Storm Lake	Buena vista	IA	Juan García Oropeza	Karen Rodríguez Pantoja	Signed	(1) The employer does not elect the employers’ liability coverage.	Evelyn R Ventura Terrazas	evelynterrazas@gmail.com	Proprietorship	Storm Lake	Buena vista	IA	Juan Garcia Oropeza	Karen Rodríguez Pantoja	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
534	2021-06-04 12:47	Anonymous (not verified)	192.119.129.187	KMA Communications, LLC	Limited Liability Company	435 croston rd. Stockport, OH 43787	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.	2021-06-04	Matthew Razen Alsup	malsupbrgi@gmail.com	Stockport	Morgan	Ohio	Stephen Alsup	Nancy Alsup	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Razen Alsup	malsupbrgi@gmail.com	Same person	Stockport	Morgan	Ohio	Stephen Alsup	Nancy Alsup	Signed
369	2021-01-22 10:02	Anonymous (not verified)	66.188.136.150	Rick Swaney	Proprietorship	1551 Persimmon, Stilwell, OK 74960	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-22	Rick Swaney	kschumacher@tricorinsurance.com	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Swaney	kschumacher@tricorinsurance.com	Same	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed
372	2021-01-25 08:38	Anonymous (not verified)	66.188.136.150	Sawa Cheroke Transport, LLC	Limited Liability Company	PO Box 168, Stilwell, OK 74960	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-25	Lisa Pritchett	kschumacher@tricorinsurance.com	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Sawa Cheroke Transport, LLC	kschumacher@tricorinsurance.com	Same	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed
1452	2023-02-13 16:49	Anonymous (not verified)	94.188.207.228	The Wine Shop, LLC	Limited Liability Company	305 Main St, 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-02-13	Dana Swasand	danaswasand@rocketmail.com	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Dana Swasand	danaswasand@rocketmail.com	Owner/Member	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed
1174	2022-06-28 07:53	Anonymous (not verified)	70.39.7.208	SG Solid Grounds	Proprietorship	402 3rd Ave SE State Center Iowa 50247	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.	2022-06-27	Stephen Graham	sgsolidgrounds@gmail.com	STATE CENTER	IA	United States	Stacie Graha	Paula Atkinson	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Graham	sgsolidgrounds@gmail.com	Owner	STATE CENTER	IA	United States	Stacie Graham	Paula Atkinson	Signed

« first
‹ previous
…
2
3
4
5
6
7
8
9
10
…
next ›
last »