1466 |
2023-02-17 15:12 |
Anonymous (not verified) |
94.188.207.230 |
BIG Roofing, LLC |
Limited Liability Company |
5751 NE 22nd St. #304 Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Tyler Jeffrey Baugh |
tj@bigroofing515.com |
Lincoln |
Lancaster |
Nebraska |
Steven Bieghler |
Andrew John Kohles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Craig Bieghler |
steve@bigroofing515.com |
Owner |
Cumming |
Dallas |
Iowa |
Tyler Jeffrey Baugh |
Andrew John Kohles |
Signed |
1474 |
2023-02-20 19:48 |
Anonymous (not verified) |
94.188.207.230 |
Individual entity |
Proprietorship |
801 CELTIC DR, Waukee IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-20 |
Gerardo Castro |
jackiecastro18@gmail.com |
Waukee |
IA |
United States |
Jackelin Castro |
Esmeralda Castro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerardo Castro |
jackiecastro18@gmail.com |
self |
Waukee |
Dallas |
Iowa |
Jackelin Castro |
Esmeralda Castro |
Signed |
1511 |
2023-03-09 15:52 |
Anonymous (not verified) |
94.188.205.177 |
CG Welding |
Limited Liability Company |
5400 147th |
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 |
Christopher A Lendt |
weldingiowa@gmail.com |
Urandale |
Dallas |
IA |
Chris Lendt |
Chris Lendt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher A Lendt |
weldingiowa@gmail.com |
Owner |
Urandale |
Dallas |
IA |
Christopher Lendt |
Christopher Lendt |
Signed |
1524 |
2023-03-20 09:00 |
Anonymous (not verified) |
94.188.205.177 |
David Roman |
Proprietorship |
8350 EP True Parkway, Apt 1101, West Des Moines, IA 50266 |
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. |
2023-03-20 |
David Roman |
vida8147@gmail.com |
West Des Moines |
Dallas |
IA |
Dario Lucas Barrera |
Alfonso Montoya |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Roman |
vida8147@gmail.com |
Self |
West Des Moines |
Dallas |
IA |
Dario Lucas Barrera |
Alfonso Montoya |
Signed |
1546 |
2023-03-29 20:53 |
Anonymous (not verified) |
94.188.205.175 |
D2 Construction LLC |
Limited Liability Company |
16192 Wendover Ave Madrid, Iowa 50156 |
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. |
2023-03-29 |
Dillon Devine |
d2construction22@gmail.com |
Madrid |
Dallas |
Iowa |
Mark Devine |
Jodie Gumm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dillon Devine |
d2construction22@gmail.com |
Owner |
Madrid |
Dallas |
Iowa |
Mark Devine |
Jodie Gumm |
Signed |
1550 |
2023-03-31 13:35 |
Anonymous (not verified) |
94.188.205.177 |
Nadarevic Group LLC |
Limited Liability Company |
3633 NW 177th Ct, Clive, IA 50325 |
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. |
2023-03-31 |
Ajdin Nadarevic |
ajdin@silverstonedevgroup.com |
Clive |
Dallas |
Iowa |
Jeremy Boysen |
Brooke Boysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ajdin Nadarevic |
ajdin@silverstonedevgroup.com |
Owner |
Clive |
Dallas |
Iowa |
Jeremy Boysen |
Brooke Boysen |
Signed |
1551 |
2023-03-31 13:37 |
Anonymous (not verified) |
94.188.205.176 |
Nadarevic Group LLC |
Limited Liability Company |
3633 NW 177th Ct, Clive, IA 50325 |
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. |
2023-03-31 |
Nicole Nadarevic |
niki@silverstonedevgroup.com |
Clive |
Dallas |
Iowa |
Jeremy Boysen |
Brooke Boysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ajdin Nadarevic |
ajdin@silverstonedevgroup.com |
Owner |
Clive |
Dallas |
Iowa |
Jeremy Boysen |
Brooke Boysen |
Signed |
1589 |
2023-04-20 12:57 |
Anonymous (not verified) |
94.188.205.167 |
Grace Flooring |
Proprietorship |
2001 W 2nd Street perry, Iowa 50220 |
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. |
2023-04-20 |
Ryan Michael Tool |
GraceFlooring0@gmail.com |
Perry |
Dallas |
IA |
Jennifer Lynn Tool |
Shane Workman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Flooring |
GraceFlooring0@gmail.com |
Owner |
Perry |
Dallas |
IA |
Jennifer Tool |
Shane workman |
Signed |
1606 |
2023-04-26 11:42 |
Anonymous (not verified) |
94.188.205.166 |
Dean Petty |
Proprietorship |
309 Locust Street De Soto |
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. |
2023-04-26 |
Dean Robert Petty |
dean.r.petty@gmail.com |
De Soto |
Dallas |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dean Robert Petty |
dean.r.petty@gmail.com |
Owner |
309 Locust Street De Soto |
Dallas |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
1607 |
2023-04-26 11:42 |
Anonymous (not verified) |
94.188.205.166 |
Dean Petty |
Proprietorship |
309 Locust Street De Soto |
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. |
2023-04-26 |
Dean Robert Petty |
dean.r.petty@gmail.com |
De Soto |
Dallas |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dean Robert Petty |
dean.r.petty@gmail.com |
Owner |
309 Locust Street De Soto |
Dallas |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
1610 |
2023-04-26 12:03 |
Anonymous (not verified) |
94.188.205.175 |
Thomas J Mullins |
Proprietorship |
6569 Vista Dr. West Des Moines, IA. 50266 |
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. |
2023-04-26 |
Thomas J Mullins |
mullinsthomasj@gmail.com |
West Des Moines |
Dallas |
IA |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas J Mullins |
mullinsthomasj@gmail.com |
Self |
West Des Moines |
Dallas |
IA |
Sheanah Wright |
Derek Mullins |
Signed |
1612 |
2023-04-27 10:37 |
Anonymous (not verified) |
94.188.207.223 |
Grind Works LLC |
Proprietorship |
26416 289th place Unit H Adel IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
Adam Samuelson |
Hello@grindworksia.com |
Adel |
Dallas |
Iowa |
Chandler Clark |
Adam Samuelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Samuelson |
Hello@Grindowrksia.com |
N/A |
Adel |
Dallas |
Iowa |
Adam Samuelson |
Chandler Clark |
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 |
1708 |
2023-06-25 15:10 |
Anonymous (not verified) |
94.188.207.228 |
Lopez concrete |
Limited Liability Company |
2009 otley ave perry Ia 50220 |
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. |
2023-06-25 |
Erick Lopez |
lopez1concrete@gmail.com |
Perry |
Dallas |
IA |
Ever tobar. |
Elba alejandro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erick lopez |
lopez1concreto@gmail.com |
Owner |
Perry |
Dallas |
IA |
Ever tobar |
Elba alejandro |
Signed |
1711 |
2023-06-26 16:50 |
Anonymous (not verified) |
94.188.207.224 |
Innovative Behavioral Therapy, LLC |
Limited Liability Company |
915 Main St. Adel IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-26 |
Ashley Andrew |
ashley@innovativebehavioraltherapy.com |
Adel |
Dallas |
Iowa |
Thomas Atherton |
Brenda Barto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ashley Andrew |
ashley@innovativebehavioraltherapy.com |
Self |
Adel |
Dallas |
Iowa |
Thomas Atherton |
Brenda Barto |
Signed |
1797 |
2023-08-14 09:37 |
Anonymous (not verified) |
94.188.205.175 |
SCG |
Limited Liability Company |
307 Bridge St. Redfield, IA 50233 |
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. |
2023-02-01 |
David Dwight Willis |
d.dubbaits@yahoo.com |
Redfield |
Dallas |
Iowa |
Lindsey Willis |
Sam Samuelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ross Turner |
RTurner@holmesmurphy.com |
Agent |
Waukee |
Dallas |
Iowa |
Brain Paterson |
Brandon DeGroff |
Signed |
1932 |
2023-12-01 20:02 |
Anonymous (not verified) |
94.188.205.168 |
Wasabi Johnston LLC |
Limited Liability Company |
2965 SE Timberline dr, Waukee, IA, 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
Enjin zheng |
jimmyzheng1573@gmail.com |
Waukee |
Dallas |
Iowa |
Jenna Yu |
Wen Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enjin zheng |
jimmyzheng1573@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Jenna Yu |
Wen Zheng |
Signed |
1933 |
2023-12-01 20:29 |
Anonymous (not verified) |
94.188.207.228 |
Wasabi Johnston LLC |
Limited Liability Company |
5106 155th Street, Urbandale, IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
Yean Ching Sue |
soamie@hotmail.com |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Yean Ching Sue |
soamie@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
1935 |
2023-12-02 18:34 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi Johnston LLC |
Limited Liability Company |
8184 Birchwood Ct, Johnston IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-02 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
Dallas |
IA |
Engjin zheng |
yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
self |
Clive |
Dallas |
IA |
Wenhui Cheng |
Enjing Zheng |
Signed |
1972 |
2024-01-02 14:19 |
Anonymous (not verified) |
94.188.205.174 |
Parker Trucking LLC |
Limited Liability Company |
1507 Greene Street Adel, IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Michael Craig Parker |
mcparker31@msn.com |
Adel |
Dallas |
Iowa |
Jessie Rynearson |
Melisha Rynearson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Parker |
mcparker31@msn.com |
Owner/Memeber |
Adel |
Dallas |
IA |
Jessie Rynearson |
Melishia Rynearson |
Signed |
1985 |
2024-01-16 11:51 |
Anonymous (not verified) |
94.188.205.167 |
Wasabi Urbandale LLC |
Limited Liability Company |
5106 155th Street, Urbandale, IA 50323 |
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. |
2024-01-16 |
Yean Ching Sue |
soamie@hotmail.com |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yean Ching Sue |
soamie@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
1986 |
2024-01-16 12:18 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi Urbandale LLC |
Limited Liability Company |
2965 Se Timberline dr , Waukee , Iowa 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Enjinzheng |
jimmyzheng1573@gmail.com |
Waukee |
Dallas |
Iowa |
Jie Li |
Yingnazheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enjin zheng |
jimmyzheng1573@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Jie Li |
Yingna zheng |
Signed |
1987 |
2024-01-16 12:35 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi urbandale LLc |
Limited Liability Company |
12509 Townsend Ava, Urbandale, IA 50323 |
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. |
2024-01-16 |
Wen Zheng |
jenna18841002@hotmail.com |
Urbandale |
Dallas |
Iowa |
Jie Li |
Yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wen Zheng |
jenna18841002@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowas |
Jie Li |
Yingna zheng |
Signed |
2003 |
2024-01-28 12:38 |
Anonymous (not verified) |
94.188.205.169 |
Wasabi Urbandale LLC |
Limited Liability Company |
2301 Rocklyn Dr, Urbandale IA 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
Dallas |
IA |
Ajdin Nadarich |
Jeremy Boysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
Self |
Clive |
Dallas |
IA |
Lisa Lee |
Yingna Zheng |
Signed |
2004 |
2024-01-28 12:41 |
Anonymous (not verified) |
94.188.205.174 |
Wasabi Urbandale LLC |
Limited Liability Company |
5106 155th Street, Urbandale, IA 50323 |
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. |
2024-01-28 |
Yean Ching Sue |
soamie@hotmail.com |
Urbandale |
Dallas |
Iowa |
Lina Zheng |
Jenna Yu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Yean Ching Sue |
soamie@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Lina Zheng |
Jenna Yu |
Signed |
2008 |
2024-01-29 14:45 |
Anonymous (not verified) |
94.188.207.230 |
DB2P |
Limited Liability Company |
5904 Ashworth Road |
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. |
2024-01-29 |
Arjun Dahal |
allcoolliquors@gmail.com |
West Des Moines |
Dallas |
Iowa |
Jayson Jones |
Nikki Wilks |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jayson Jones |
jayson@jonesinsured.com |
Insurance Agent |
Urbandale |
Dallas |
Iowa |
Jayson Jones |
Nikki Wilks |
Signed |
2015 |
2024-02-01 08:26 |
Anonymous (not verified) |
94.188.207.223 |
Salazar Builders inc |
Proprietorship |
29175 365th st van meter 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. |
2024-02-01 |
José Luis ángeles Salazar |
salazarbuilders15@gmail.com |
Van meter ia |
Dallas |
Iowa |
Adam Paul Boge |
Lance Owen Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Luis angeles Salazar |
salazarbuilders15@gmail.com |
Sub contractor |
Van meter |
Dallas |
Iowa |
Adam Paul Boge |
Lance Owen Webster |
Signed |
2077 |
2024-03-06 11:08 |
Anonymous (not verified) |
94.188.205.177 |
Randy's all Right painting |
Proprietorship |
24531n.ave Dallas center iowa po 445 |
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. |
2024-03-06 |
David keasey |
keaseyshideaway@gmail.com |
Dallas center |
Dallas |
Iowa |
Angela Johnston |
Robin Vilz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David keasey |
keaseyshideaway@gmail.com |
Self |
Dallas center |
Dallas |
Iowa |
Angela Johnston |
Robin Volz |
Signed |
2113 |
2024-03-23 10:21 |
Anonymous (not verified) |
94.188.205.166 |
D2 Construction |
Limited Liability Company |
16192 wendover ave Madrid Ia 50156 |
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. |
2024-03-23 |
Dillon Devine |
d2construction22@gmail.com |
Madrid |
Dallas |
Iowa |
Chelsey devine |
Jodie Gumm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dillon devine |
d2construction22@gmail.com |
Self |
Madrid |
Dallas |
Iowa |
Chelsey devine |
Jodie gumm |
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 |
2170 |
2024-04-22 10:11 |
Anonymous (not verified) |
94.188.207.224 |
Joy Ride Transport |
Limited Liability Company |
3105 SE Miehe Drive, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ted Cochran |
ted@ridejoyride.com |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Cochran |
ted@ridejoyride.com |
Self |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
2172 |
2024-04-22 14:09 |
Anonymous (not verified) |
94.188.205.167 |
Melissa J Madison |
Proprietorship |
326 NE Olivewood Waukee, IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Melissa Janelle Madison |
melissamadison01@gmail.com |
Waukee |
DALLAS |
IOWA |
Haley Sears |
Scott Leinen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Madison |
melissamadison01@gmail.com |
myself |
Waukee |
Dallas |
Iowa |
Haley Sears |
Scott Leinen |
Signed |
451 |
2021-03-25 17:00 |
Anonymous (not verified) |
166.181.80.120 |
Rogers conc,. const, |
Partnership |
220804 CO, RD, ANAMOSA IA, 52205 |
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. |
2021-04-25 |
Alex olah |
aolah43@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Robin marie kane |
Augie rodreguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin johnson |
kevinecollins@libertymutual.com |
Ins , Agent |
Appleton |
Dane |
Wisconsin |
Robin marie kane |
Augie Rodriguez |
Signed |
1262 |
2022-08-16 12:52 |
Anonymous (not verified) |
74.137.151.70 |
Golds Custom Grading LLC |
Limited Liability Company |
Po Box 114 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. |
2022-08-16 |
Brad Carlson |
brad_carlson@gmail.com |
Spencer |
Clay |
Iowa |
Thomas Dunn |
Nancy Cassa |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Thomas Dunn |
TDUNN@THOMASBRADLEYINSURANCE.COM |
Agent |
Madison |
Dane |
Wisconsin |
Nancy Cassa |
Brad Carlson |
Signed |
1642 |
2023-05-12 07:29 |
Anonymous (not verified) |
94.188.205.169 |
HARI SWAMI LLC |
Limited Liability Company |
2759 Mt Pleasant St, Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
BRANDON KELLY |
MARKWILLIAMSPRO@GMAIL.COM |
FRUIT HEIGHTS |
DAVIS |
UTAH |
MARK WILLIAMS |
GREG VANCAMP |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BRANDON KRLLY |
MARKWILLIAMSPRO@GMAIL.COM |
SELF |
FRUIT HEIGHTS |
DAVIS |
UTAH |
MARK WILLIAMS |
GREG VANCAMP |
Signed |
112 |
2020-04-07 12:16 |
Anonymous (not verified) |
173.27.33.108 |
Josh Alley Siding |
Proprietorship |
205 N Oak St. Davis City, IA 50065 |
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. |
2018-04-10 |
Joshua H. Alley |
alley.josh@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Alley Siding |
alley.josh@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
113 |
2020-04-07 12:30 |
Anonymous (not verified) |
173.27.33.108 |
Aarron Alley |
Proprietorship |
101 S Teale 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2018-05-15 |
Aarron Alley |
aarronalley10@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aarron Alley |
aarronalley10@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
308 |
2020-11-08 09:17 |
Anonymous (not verified) |
173.27.33.108 |
Aarron Alley |
Proprietorship |
101 S Teale St. Davis City, 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. |
2019-11-01 |
Aarron Alley |
aarronalley10@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aarron Alley |
aarronalley10@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
22 |
2020-01-02 14:52 |
Anonymous (not verified) |
173.17.129.166 |
Dan & Sarah Gudenkauf |
Proprietorship |
3277 180th Ave, Ryan, IA 52330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-02 |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Owner |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
23 |
2020-01-02 14:54 |
Anonymous (not verified) |
173.17.129.166 |
Dan Gudenkauf |
Proprietorship |
3277 180th Ave, Ryan, IA 52330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-02 |
Dan Gudenkauf |
dandselectricmotor@gmail.com |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Gudenkauf |
dandselectricmotor@gmail.com |
Owner |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
28 |
2020-01-06 13:39 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
GREELEY |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
OWNER |
GREELEY |
DELAWARE |
IA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
29 |
2020-01-06 13:44 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
DAVID MULLIS |
JAMES@CIOIA.COM |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DAVID MULLIS |
JAMES@CIOIA.COM |
OWNER |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
203 |
2020-07-15 09:39 |
Anonymous (not verified) |
166.181.66.222 |
High Caliber Fiber |
Limited Liability Company |
2958 110th ave masonville IA, 50654 |
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. |
2020-07-15 |
Chris cooper |
chris_cooper@highcaliberfiber.com |
Masonville |
Delaware |
Iowa |
Nick beranek |
Nicole kintzle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
chris_cooper@highcaliberfiber.com |
N/A |
Masonville |
Delaware |
Iowa |
Nick beranek |
Nicole kintzle |
Signed |
211 |
2020-07-20 15:30 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th Ave Masonville IA 50654 |
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. |
2020-07-20 |
Chris |
Chris_cooepr@highcaliberfiber.com |
masonville |
Delaware |
IA |
NIck Beranek |
Nicole KIntzle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
Self |
Masonville |
Delaware |
IA |
Nick Beranek |
Nicole Kintzle |
Signed |
590 |
2021-07-29 16:38 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Joshua Arthur Soppe |
choiceagservices@gmail.com |
Manchester |
Delaware |
Iowa |
Dustin Fessler |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Arthur Soppe |
choiceagservices@gmail.com |
Owner |
Manchester |
Delaware |
Iowa |
Dustin Fessler |
Adam Reth |
Signed |
591 |
2021-07-29 16:42 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Dustin Fessler |
dustin@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Fessler |
dustin@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Adam Reth |
Signed |
592 |
2021-07-29 16:44 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Adam Reth |
adam@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Reth |
adam@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Dustin Fessler |
Signed |
1160 |
2022-06-20 10:08 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th ave masonville IA, 50654 |
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. |
2022-06-20 |
chris cooper |
Chris_cooper@highcaliberfiber.com |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
Blake Dean Elbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
self |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
BLake Dean Elbert |
Signed |
1179 |
2022-07-05 12:21 |
Anonymous (not verified) |
173.18.233.175 |
Crossline Contracting LLC |
Limited Liability Company |
2009 Wilson Ave SW, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Adam Anderson |
crosslinecontracting319@gmail.com |
Ryan, IA |
Deleware |
Iowa |
Branden Peters |
Todd Philpott |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Crossline Contracting LLC |
crosslinecontracting319@gmail.com |
Self |
Ryan Iowa |
Deleware |
Iowa |
Branden Peters |
Todd Philpott |
Signed |