1324 |
2022-09-30 10:19 |
Anonymous (not verified) |
172.86.18.249 |
Red Beard Buildings |
Limited Liability Company |
511 16th St. Belle Plaine, IA 52208 |
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. |
2022-09-30 |
Austin Carnes |
austin_carnes@hotmail.com |
Belle Plaine |
Benton |
IA |
Craig Roster |
Connor Doran |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Carnes |
austin_carnes@hotmail.com |
President |
Belle Plaine |
Benton |
IA |
Craig Roster |
Connor Doran |
Signed |
862 |
2022-01-27 12:02 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction,LLC |
Limited Liability Company |
4508 Hiawatha Ave NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Michael Allen Becker |
mike4bbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Brother/partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
863 |
2022-01-27 12:13 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction llc |
Limited Liability Company |
4508 Hiawatha Ave ne Cedar Rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Allen Becker |
mike4bbc@gmail.com |
Brother/Partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
1122 |
2022-05-21 12:19 |
Anonymous (not verified) |
173.24.108.210 |
Daly Building Service,LLc |
Limited Liability Company |
409 Dammann dr. Eldridge IA, 52748 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-21 |
Noah Daly |
Noahdalyubs@gmail.com |
Eldridge |
Scott County |
Iowa |
Holly Roberts |
Corinna Daly |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derick Perry |
biglakellc@outlook.com |
Liability policy agent |
Eldridge |
Scott county |
Iowa |
Holly roberts |
Corinna Daly |
Signed |
1331 |
2022-10-11 13:17 |
Anonymous (not verified) |
174.216.2.52 |
Parceros Construction LLC |
Limited Liability Company |
2315 Landon Rd. Apt. 206 North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-11 |
Laura Garavito |
ldanielagaravitog@gmail.com |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura Garavito |
ldanielagaravitog@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
312 |
2020-11-11 18:12 |
Anonymous (not verified) |
173.16.216.53 |
Skb transportation llc |
Limited Liability Company |
401 6th street west amana iowa 52203 |
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 |
Scott Wayne bryant |
skbtransportation@icloud.com |
West amana |
Iowa |
Iowa |
Nichole prokop |
Cory prokop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Wayne bryant |
skbtransportation@icloud.com |
Owner |
West amana |
Iowa |
Iowa |
Nichole prokop |
Cory prokop |
Signed |
1095 |
2022-05-12 13:20 |
Anonymous (not verified) |
173.31.29.53 |
Leaf cutter protection |
Limited Liability Company |
4146 East 23rd Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-05-12 |
Gideon Lagat |
gsaina78@gmail.com |
Des Moines |
IA |
United States |
Priscilla saina |
Cosmas nyaika |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark rond |
mbond@leaffilter.com |
Regional installation Manager |
Grimes |
Polk |
Iowa |
Priscilla saina |
Cosmas nyaika |
Signed |
1402 |
2022-12-28 16:35 |
Anonymous (not verified) |
208.69.145.91 |
DeRonde Flooring Inc. |
Proprietorship |
3612 NW 178th 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. |
2022-12-28 |
Brian DeRonde |
derondeflooring@gmail.com |
Clive |
Dallas |
IA |
Brian DeRonde |
Courtney DeRonde |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian DeRonde |
derondeflooring@gmail.com |
Self |
Clive |
Dallas |
IA |
Brian DeRonde |
Courtney DeRonde |
Signed |
1971 |
2023-12-29 19:27 |
Anonymous (not verified) |
94.188.207.223 |
Megan Thibodeau |
Proprietorship |
4301 Adams Ave, Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-29 |
Megan E Thibodeau |
megancallan@hotmail.com |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan E Thibodeau |
megancallan@hotmail.com |
Self |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
Signed |
1267 |
2022-08-17 14:11 |
Anonymous (not verified) |
174.192.75.162 |
Elijah wyant |
Proprietorship |
708 1/2 w 3rd st davenport ia 52802 |
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. |
2022-08-17 |
Elijah wyant |
Aidenwyant@gmail.com |
Davenport |
Scott |
Iowa |
Jake laxton |
Courtney sanders |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elijah wyant |
Aidenwyant@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Jake laxton |
Courtney sanders |
Signed |
405 |
2021-02-17 11:04 |
Anonymous (not verified) |
104.201.67.178 |
CYE Painting |
Limited Liability Company |
5202 SE 31st Ct Des Moines,IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-17 |
CYE Painting |
marilopez9657@yahoo.com |
Des Moines |
Polk |
Iowa |
Maricela Lopez |
Cruz Cabrera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maricela Lopez |
marilopez9657@yahoo.com |
N/a |
Des Moines |
Polk |
IA |
Maricela Lopez |
Cruz Cabrera |
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 |
1577 |
2023-04-17 09:58 |
Anonymous (not verified) |
94.188.205.167 |
Four Leaf LLC |
Limited Liability Company |
11150 NE 72nd St Bondurant IA 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Eric O'Shea |
Fourleaf2021@gmail.com |
Bondurant |
IA |
United States |
Lucas Gray |
Curt Decker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Michael O'Shea |
Fourleaf2021@gmail.com |
Owner |
Bondurant |
IA |
United States |
Lucas Gray |
Curt Decker |
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 |
824 |
2022-01-06 20:57 |
Anonymous (not verified) |
209.252.175.92 |
Rottweiler Remodel & Repair LLC |
Limited Liability Company |
1503 10th Ave Sw Cedar Rapids Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-06 |
Zechariah Robert DeLaVergne |
rottweilerremodel@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Kathy Maxine Morgan |
Daisha Rae Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zechariah DeLaVergne |
rottweilerremodel@gmail.com |
Owner |
Cedar Rapids |
Linn County |
Iowa |
Kathy Maxine Morgan |
daisha rae gonzalez |
Signed |
2181 |
2024-04-25 15:41 |
Anonymous (not verified) |
94.188.205.168 |
Ev's Ice Cream LLC |
Limited Liability Company |
2205 1/2 S Center St, Marshalltown, IA 50158-5960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-25 |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Self |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
1128 |
2022-05-26 11:11 |
Anonymous (not verified) |
174.213.144.187 |
Leaf Filter |
Limited Liability Company |
3060 se grimes blvd suite 100-300 Grimes iowa 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. |
2022-05-24 |
Jason charlet |
jasonstreeservice2014@gmail.com |
Minburn |
Dallas |
Iowa |
Kami lillibridge |
Dale charlet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
N/a |
jasoncharlet703@gmail.com |
N/a |
N/a |
N/a |
N/a |
N/a |
N/a |
Signed |
964 |
2022-03-10 12:41 |
Anonymous (not verified) |
107.115.239.27 |
KG Land Works LLC |
Limited Liability Company |
P.O. Box 931 Barnsdall Ok 74002 |
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. |
2022-03-10 |
Colton Kelley |
kglandworks@gmail.com |
Barnsdall |
Osage |
Oklahoma |
Colton Kelley |
Dalton Gardner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Owner |
Barnsdall |
Osage |
Oklahoma |
Colton Kelley |
Dalton Gardner |
Signed |
1121 |
2022-05-19 17:45 |
Anonymous (not verified) |
107.115.239.35 |
KG Land works LLC |
Limited Liability Company |
P.O. Box 931Barnsdall Oklahoma 74002 |
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. |
2022-05-19 |
Keiven Brooke Slone |
keiven.slone@gmail.com |
Barnsdalll |
Osage |
OK |
Colton Kelley |
Dalton Gardner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Owner |
Barnsdalll |
Osage |
OK |
Dalton Garder |
Jacob Kelley |
Signed |
1428 |
2023-01-23 19:31 |
Anonymous (not verified) |
206.72.6.241 |
Brian Grote |
Limited Liability Company |
919 Highway 37 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-23 |
Brian Grote |
grote919@gmail.com |
Earling |
Iowa |
United States |
Jaurel Grote |
Dan Grote |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leinen Construction |
grote919@gmail.com |
sub |
Harlan Iowa |
Iowa |
United States |
Jaurel Grote |
Dan Grote |
Signed |
483 |
2021-04-16 10:47 |
Anonymous (not verified) |
204.155.61.217 |
Joseph Jones DBA Jones Sealcoating and Asphalt Repair |
Limited Liability Company |
1033 Hummingbird Cir |
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. |
2021-04-16 |
Joseph Jones |
iscrapcu@yahoo.com |
Waterloo |
Iowa |
Iowa |
Kyle Hildman |
Dan Sinnott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jospeh Jones |
iscrapcu@yahoo.com |
OWNER |
Waterloo |
Black Hawk |
IA |
Kyle Hildman |
Dan Sinnott |
Signed |
639 |
2021-09-13 16:10 |
Anonymous (not verified) |
50.81.97.207 |
Copic Home Maintenance LLC dba Des Moines Drywall Repair |
Limited Liability Company |
1548 24th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-13 |
Clint R Copic |
crcopic@gmail.com |
Des Moines |
Polk |
Iowa |
Veronica G. Torres |
Dan Waidelich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clint R Copic |
dmdrywallrepair@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Veronica G Torres |
Dan Waidelich |
Signed |
376 |
2021-01-26 11:14 |
Anonymous (not verified) |
173.28.210.45 |
Cross Medical Lab, L.L.P |
Limited Liability Partnership |
500 E Market St Iowa City IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-26 |
Aaron Klein |
lhavel_23@gmail.com |
Iowa City |
Johnson |
Iowa |
Ashley Lee |
Dan Wegman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Havel |
lhavel_23@gmail.com |
Office Manager |
Iowa CIty |
Johnson |
IA |
Ashley Lee |
Dan Wegman |
Signed |
530 |
2021-05-25 08:30 |
Anonymous (not verified) |
159.242.43.24 |
FoxTrot Foods, LLC |
Limited Liability Company |
13-15 S Federal Ave, Mason City IA 50401 |
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. |
2021-05-25 |
Melissa Fabian |
melissafabian@yahoo.com |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Fabian |
melissafabian@yahoo.com |
Owner-Member |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
697 |
2021-10-28 15:30 |
Anonymous (not verified) |
208.126.114.236 |
bartman express |
Limited Liability Company |
1976 240th st bennett iowa 52721 |
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. |
2021-10-28 |
bartin joesph steines |
bartmanexpress@gmail.com |
bennett |
cedar |
iowa |
Robert theordore jarrett |
dana marie shipler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
bartin joesph steines |
bartmanexpress@gmail.com |
self |
bennett |
cedar |
iowa |
robert theordore jarrett |
dana marie shipler |
Signed |
773 |
2021-11-24 14:48 |
Anonymous (not verified) |
24.149.18.237 |
The Ragged Edge Art Bar and Gallery |
Limited Liability Company |
504 Bluff Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-24 |
Kendra Wohlert |
kwohlert43@gmail.com |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendra Wohlert |
kwohlert43@gmail.com |
self |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
288 |
2020-10-21 18:36 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
1451 |
2023-02-13 13:27 |
Anonymous (not verified) |
94.188.205.168 |
Better Built Floors, LLC |
Limited Liability Company |
950 Spruce street 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. |
2023-02-13 |
Bodhi Cox |
betterbuiltfloors@gmail.com |
waukee |
dallas |
iowa |
Bodhi Cox |
Daniel Cox |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bodhi Cox |
betterbuiltfloors@gmail.com |
i am thge owner/operator |
waukee |
dallas |
iowa |
Bodhi Cox |
Daniel Cox |
Signed |
325 |
2020-11-23 11:14 |
Anonymous (not verified) |
174.198.82.169 |
Dan davidson |
Limited Liability Company |
21Lincoln 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-11-22 |
Daniel Lee davidson |
unitedremodelingdd@gmail.com |
Palo |
Linn |
IA |
Daniel Lee davidson |
Daniel Lee davidson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Daniel Lee davidson |
unitedremodelingdd@gmail.com |
Owner |
Palo |
Linn |
IA |
Daniel Lee davidson |
Daniel Lee davidson |
Signed |
775 |
2021-12-02 11:40 |
Anonymous (not verified) |
65.144.174.26 |
Pedro Campos |
Proprietorship |
16901 SW 13th St, Des Moines, IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-02 |
Pedro Campos |
camposp113@msn.com |
Des Moines |
Polk |
IA |
Antonio Campos |
Daniel Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Campos |
camposp113@msn.com |
Self |
Des Moines |
Polk |
Iowa |
Antonio Campos |
Daniel Perez |
Signed |
1773 |
2023-08-03 08:24 |
Anonymous (not verified) |
94.188.207.226 |
LR Construction LLC |
Limited Liability Company |
1564 110th Street, Hazleton, IA 50641 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-23 |
Levi R Raber |
leviraber@amish.com |
Hazleton |
Buchanan |
Iowa |
Mary Ann Reber |
Daniel Raber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levi R Raber |
leviraber@amish.com |
self |
Hazleton |
Buchanan |
Iowa |
Julie Schick |
Kelly Matt |
Signed |
1840 |
2023-09-14 13:48 |
Anonymous (not verified) |
94.188.207.228 |
L.R. Construction, LLC |
Limited Liability Company |
1564 110th Street, Hazleton, IA 50641 |
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. |
2023-02-23 |
Levi R Raber |
amish@amish.com |
Hazleton |
Buchanan |
Iowa |
Mary Ann Raber |
Daniel Raber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levi R Raber |
amish@amish.com |
self |
Hazleton |
BUCHANAN |
Iowa |
Mary Ann Raber |
Daniel Raber |
Signed |
1288 |
2022-08-30 16:23 |
Anonymous (not verified) |
50.83.35.94 |
Black Rock Flooring LLC |
Limited Liability Company |
189 9th st. Marion,Ia 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-30 |
Keith Douglas Luye Sr. |
Blackrockflooriing@gmail.com |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Douglas Luye Sr. |
Blackrockflooring@gmail.com |
self / my own authorized agent |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
242 |
2020-08-24 09:27 |
Anonymous (not verified) |
159.242.43.24 |
Bontreger Seamless Gutters |
Proprietorship |
501 S Center St. Zearing Ia 50278 |
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. |
2020-08-24 |
Harvey Bontreger |
borntrgerharvey@gmail.com |
Zearing |
Story |
Ia |
Alex G Meier |
Daniel Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Harvey Bontreger |
borntrgerharvey@gmail.com |
Owner |
Zearing |
Story |
Ia |
Alex G Meier |
Daniel Wunschel |
Signed |
243 |
2020-08-24 11:31 |
Anonymous (not verified) |
159.242.43.24 |
Borntreger Seamless Gutters |
Proprietorship |
501 S Center St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-24 |
Harvey Borntrager |
Borntregerharvey@gmail.com |
Zearing |
Story |
Ia |
Alex G Meier |
Daniel Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Harvey Borntreger |
borntregerharvey@gmail.com |
Owner |
Zearing |
Story |
Ia |
Alex Meier |
Daniel Wunschel |
Signed |
1906 |
2023-11-14 13:47 |
Anonymous (not verified) |
94.188.207.223 |
HRBC Plus |
Limited Liability Company |
249 SOLOMIA CT, Peosta, IA 52068 |
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. |
2023-11-11 |
Lori S Stewart |
lori@hrbcplus.com |
PEOSTA |
Dubuque |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Stewart |
lori@hrbcplus.com |
Self |
Peosta |
Dubuque |
United States |
Mark R Stewart |
Danielle M Peterson |
Signed |
1874 |
2023-10-22 11:54 |
Anonymous (not verified) |
94.188.205.166 |
Midwest UAV LLC |
Limited Liability Company |
1400 15th St SE Bondurant Iowa 50035 |
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. |
2023-10-22 |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Owner |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
362 |
2021-01-14 12:15 |
Anonymous (not verified) |
173.26.157.255 |
Shear Bliss Pet Salon |
Limited Liability Company |
824 Ansborough Ave. Waterloo, IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-14 |
Sarah K Bebee |
shearblisspet@aol.com |
Hudson |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Bebee |
shearblisspet@aol.com |
self |
Hudson |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
363 |
2021-01-14 12:17 |
Anonymous (not verified) |
173.26.157.255 |
Shear Bliss Pet Salon |
Limited Liability Company |
824 Ansborough Ave. Waterloo, IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-14 |
Melissa Kay Herold |
shearblisspet@aol.com |
Cedar Falls |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meliss Kay Herold |
shearblisspet@aol.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
1909 |
2023-11-15 12:27 |
Anonymous (not verified) |
94.188.207.228 |
CHAR-LES BUILDINGS LLC |
Limited Liability Company |
14633 7TH AVE NW, ANDOVER MN 55304 |
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 |
JOHNNY CHAVEZ CHAVEZ |
charlychavez151@gmail.com |
ANDOVER |
ANOKA |
MINNESOTA |
ALEIDA LEE |
DANY JIMBO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHNNY CHAVEZ CHAVEZ |
charlychavez151@gmail.com |
OWNER |
ANDOVER |
ANOKA |
MINNESOTA |
ALEIDA LEE |
DANY JIMBO |
Signed |
1323 |
2022-09-28 22:45 |
Anonymous (not verified) |
74.51.212.66 |
OUTDOOR MODERN CONCEPTS LLC |
Limited Liability Company |
2520 RIVER MEADOWS DR., DES MOINES, IA, 50320 |
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. |
2022-09-28 |
CHRISTIAN RUBIO |
RUBIOCH39@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
AMANDA DUPRE |
DARCI CLARK |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JENNIFER B. CHAVEZ-RIVERA |
JENNIFER.CHAVEZ-RIVERA@BROWNWINICK.COM |
ATTORNEY |
DES MOINES |
POLK |
IOWA |
AMANDA DUPRE |
DARCI CLARK |
Signed |
1859 |
2023-10-04 07:54 |
Anonymous (not verified) |
94.188.205.167 |
Pacheco Constructrion |
Limited Liability Company |
1614 Center Street, Des Moines IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-04 |
Ulises Pacheco |
info@pachecoconstruction.com |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ulises Pacheco |
info@pachecoconstruction.com |
Self |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
826 |
2022-01-10 12:26 |
Anonymous (not verified) |
104.128.43.204 |
Wolfman Trucking, LLC |
Limited Liability Company |
406 S Lawrence St, Bazine, KS 67516 |
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. |
2022-01-10 |
JR Steckline |
wolfmantrucking317@gmail.com |
Bazine |
Ness |
Kansas |
James Babcock |
Darin Wittman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JR Steckline |
wolfmantrucking317@gmail.com |
Owner |
Bazine |
Ness |
Kansas |
James Babcock |
Darin Wittman |
Signed |
1954 |
2023-12-13 13:51 |
Anonymous (not verified) |
94.188.207.227 |
Beeson Trucking LLC |
Limited Liability Company |
219 Tilden St Kingsley IA 51028 |
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. |
2023-12-13 |
Jeremy Beeson |
jeremy4k78@yahoo.com |
Kingsley |
Plymouth |
IA |
Katherine Weaver |
Darla Robley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremy Beeson |
jeremy4k78@yahoo.com |
Self |
Kingsley |
Plymouth |
IA |
Katherine Weaver |
Darla Robley |
Signed |
2072 |
2024-03-01 11:27 |
Anonymous (not verified) |
94.188.207.226 |
SoldFast Real Estate L.L.C. |
Limited Liability Company |
5525 Meredith Drive Des Moines, Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-02 |
Darlyn Fructuoso |
thejjscleaningllc@gmail.com |
Des Moines |
Polk |
IA |
Beatriz Musselman |
Darlyn Fructuoso |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Wilkinson |
cody@soldfast.com |
Contractor |
Des Moine |
Polk |
IA |
Beatriz Musselman |
Darlyn Fructuoso |
Signed |
49 |
2020-01-31 12:53 |
Anonymous (not verified) |
74.84.121.206 |
Cody Kleppe |
Proprietorship |
1891 337th St Decorah IA 52101 |
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. |
2020-01-31 |
Cody Kleppe |
darrele@ciains.biz |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1338 |
2022-10-17 15:53 |
Anonymous (not verified) |
74.84.121.206 |
Mark Mitchell |
Proprietorship |
P O Box 38 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-15 |
Mark Mitchell |
darrele@ciains.biz |
New Albion |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Mitchell |
darrele@ciains.biz |
Self |
New Albion |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1394 |
2022-12-14 14:31 |
Anonymous (not verified) |
74.84.121.206 |
Benjamin Salo |
Proprietorship |
320 Plat St Lansing, IA 52151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-09 |
Benjamin Salo |
benwa011@gmail.com |
Lansing, Iowa |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benjamin Salo |
benwa011@gmail.com |
self |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1489 |
2023-02-28 16:06 |
Anonymous (not verified) |
94.188.207.228 |
Nate's Tractor LLC |
Limited Liability Company |
11939 birch Ave Riceville, IA 50466 |
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. |
2023-02-28 |
Nathan Fox |
nate@natestractor.com |
Riceville |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Fox |
nate@natestractor.com |
Member |
Riceville |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1903 |
2023-11-13 09:08 |
Anonymous (not verified) |
94.188.207.228 |
Christopher Stone |
Proprietorship |
2427 S Taft Ave Apt #8 |
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. |
2023-11-10 |
Christopher Stone |
darrele@ciains.biz |
Iowa |
Cerro Gordo |
IA |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Stone |
darrele@ciains.biz |
self |
Mason City |
Cerro Gordo |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |