Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 451 - 500 of 2219. Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.

#	Submitted	User	IP address	Name of Employer:	Type of Entity:	Address of Employer's Home Office:	Statement 1 Agreement:	Statement 2 Agreement:	Statement 3 Agreement:	Understanding Confirmation:	Check Either Alternative (1) or (2):	Date:	Full Name of Individual:	Email:	City of Residence:	County of Residence:	State of Residence:	Full Name of Witness 1:	Full Name of Witness 2:	Signing Indication:	Check either alternative (1) or (2):	Full Name of Authorized Agent:	Email of Authorized Agent:	Relationship to Employer of Authorized Agent:	City of Residence:	County of Residence:	State of Residence:	Full Name of Witness No. 1:	Full Name of Witness No. 2:	Signing Indication:
1363	2022-11-08 11:37	Anonymous (not verified)	69.76.241.21	S&M Veteran Contracting	Proprietorship	1529 E Ave NW Cedar Rapids, IA 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-08	Shane Little	smveterancontracting@gmail.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Clay	MO	Jordan Loyd	Joshua Lafond	Signed
2196	2024-05-01 09:18	Anonymous (not verified)	94.188.207.230	Penaloza Stone LLC	Limited Liability Company	1530 8th St Des Moines IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-01	Javier Marcial Penaloza	javiermarcial.jmp@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier Marcial Penaloza	javiermarcial.jmp@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
867	2022-01-28 12:19	Anonymous (not verified)	207.199.212.86	Gary Elsbernd DBA RGM Dairy Farm	Proprietorship	1538 230th St Calmar IA, 52132	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.	2022-01-21	Gary Elsbernd	lacy@cioia.com	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Elsbernd	lacy@cioia.com	Self	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed
868	2022-01-28 12:22	Anonymous (not verified)	207.199.212.86	Gary Elsbernd DBA RGM Dairy Farm	Proprietorship	1538 230th St Calmar IA, 52132	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.	2022-01-21	Marie Elsbernd	lacy@cioia.com	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed	(1) The employer does not elect the employers’ liability coverage.	Marie Elsbernd	lacy@cioia.com	Spouse	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed
1255	2022-08-15 11:18	Anonymous (not verified)	173.215.77.92	Abby Snyder Design LLC	Limited Liability Company	1540 SE Greenbriar Circle, 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.	2022-08-15	Abby Mae Snyder	abby.mae.snyder@gmail.com	Waukee	Dallas	Iowa	Jenni Wiig	Katy Hildman	Signed	(1) The employer does not elect the employers’ liability coverage.	Abby Mae Snyder	abby.mae.snyder@gmail.com	Self	Waukee	Dallas	Iowa	Jenni Wiig	Katy Hildman	Signed
1271	2022-08-19 08:40	Anonymous (not verified)	75.162.65.221	William Ryerson	Proprietorship	15423 Aurora Ave, 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.	2022-08-19	William Ryerson	churchgirl488@yahoo.com	Urbandale	Dallas	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	William Ryerson	churchgirl488@yahoo.com	Self	Urbandale	Dallas	Iowa	Randy Lacina	Laura Lacina	Signed
637	2021-09-10 15:15	Anonymous (not verified)	204.155.61.217	Duwa Waterproofing LLC	Limited Liability Company	1548 150th 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.	2021-09-10	Stacy Duwa	duwawaterproofing@gmail.com	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	owner	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	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
1410	2023-01-06 10:58	Anonymous (not verified)	173.25.103.95	Bryce Kenworthy	Proprietorship	155 NW Maple St Elkhart IA 50073	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.	2023-01-06	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Owner	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed
1357	2022-11-03 15:06	Anonymous (not verified)	66.129.196.99	Blake Carson	Limited Liability Company	1550 plainview rd ely, IA 52227	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	Blake Dennis Carson	Blake@carsondesignsco.com	Ely	Linn	iowa	Dennis Carson	Jordan Mellinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Carson	Blake@carsondesignsco.com	member/Owner	Ely	linn	iowa	Dennis Carson	Jordan Mellinger	Signed
369	2021-01-22 10:02	Anonymous (not verified)	66.188.136.150	Rick Swaney	Proprietorship	1551 Persimmon, Stilwell, OK 74960	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-22	Rick Swaney	kschumacher@tricorinsurance.com	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Swaney	kschumacher@tricorinsurance.com	Same	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed
716	2021-11-05 13:22	Anonymous (not verified)	209.252.172.87	Rick Clifford Clifford Custom Tile & Flooring	Proprietorship	1563 Palmer Ct NE, Solon, IA 52333	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-24	Rick Clifford	cliffordcustomtile@gmail.com	Solon	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Clifford Clifford Custom Tile & Flooring	cliffordcustomtile@gmail.com	Self Employed	Solon	Johnson	Iowa	Sarah Coberley	Heather Howell	Signed
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
819	2022-01-02 11:39	Anonymous (not verified)	184.94.130.66	derek verhelst trucking inc	Proprietorship	1579 270th avenue canby mn 56220	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.	2022-01-02	derek verhelst	derekvtinc@gmail.com	canby	yellow medicine	mn	lois verhelst	dylan nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	derek verhelst	derekvtinc@gmail.com	owner	canby	yellow medicine	mn	lois verhelst	dylan nelson	Signed
556	2021-07-07 09:16	Anonymous (not verified)	66.188.136.150	William Campbell	Proprietorship	159 Friendly Blvd. Springfield, IL 62707	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.	2021-07-06	William Campbell	kschumacher@tricorinsurance.com	Springfield	Sangamon	IL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	William Campbell	kschumacher@tricorinsurance.com	Same	Springfield	Sangamon	IL	Mitch Kemp	Shuree Behr	Signed
1377	2022-11-21 13:06	Anonymous (not verified)	166.181.84.102	Leaf home solutions	Proprietorship	1595 George Town road Hudson Ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-21	Christopher da von carpenter	chris.carpenter9595@icloud.com	Pleasant hill	Polk	Iowa	Clara Francis carpenter	Thrinadh gutta	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher da von carpenter	chris.carpenter9595@icloud.com	Self	Pleasant hill	Polk	Iowa	Clara Francis carpenter	Thrinadh gutta	Signed
1569	2023-04-12 16:19	Anonymous (not verified)	94.188.205.166	Leaf home solutions llc	Limited Liability Partnership	1595 Georgetown rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-11	Gustavo Lopez	Glopez2616@gmail.com	Des Moines	IA	IA	Ricardo lopez	Maria lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	N/a	sewell@leafhome.com	N/a	Na	Na	Na	Na	Na	Signed
1443	2023-02-07 10:05	Anonymous (not verified)	166.181.84.211	Leaf home solutions	Limited Liability Company	1595 Georgetown rd Hudson Ohio 44236	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.	2023-02-07	Dean Martells	dn.mardesconstruction@gmail.com	Laporte city	Benton	Ia	Jeromia wilson	Todd mcknees	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Yurko	byurko@leacome.com	Recruiter	Hudson	Summit	Ohio	Brian mako	Mat kaulig	Signed
624	2021-08-30 15:53	Anonymous (not verified)	174.253.66.113	Leaf Home Solutions LLC	Limited Liability Company	1595 Georgetown Rd.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Chad York	Cyork027@gmail.com	Davenport	Scott	Iowa	Chad York	Adam Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Coleman	ARColeman@leafhome.com	Recruiter	Hudson	Summit	Ohio	Chad York	Adam Coleman	Signed
791	2021-12-14 11:35	Anonymous (not verified)	108.178.194.186	Leaf Home solutions LLC	Limited Liability Company	1595 Georgetown rd. Hudson OH 44236	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.	2023-12-14	Abelardo Lino Montes	alinomontes@gmail.com	Le claire IA 52753	Scott	Iowa	Ann Pelton	Herman Roche	Signed	(1) The employer does not elect the employers’ liability coverage.	Abelardo Lino Montes	alinomontes@gmail.com	Owner	Le Claire	Scott	IA	Ann Pelton	Herman Roche	Signed
1924	2023-11-27 12:17	Anonymous (not verified)	94.188.205.166	Leaf Home LLC	Limited Liability Company	1595 Georgetown Rd. Hudson, OH 44236	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.	2023-11-27	Nathaniel Brundidge	nateotto1313@gmail.com	Osceola	Warren	IA	Barb Dryer	Bob Dryer	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Acosta	macosta@leafhome.com	Employee	Hudson	Summit	Ohio	Barb Dryer	Bob Dryer	Signed
1436	2023-02-01 11:53	Anonymous (not verified)	174.215.242.112	Leaf home solutions	Limited Liability Company	1595 Georgetown Rd. Hudson, Ohio 44236	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	Edward Koch	etkdbq@aol.com	Waterloo	IA	United States	Glenda mclarty	Coen Koch	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian yurko	byurko@leafhome.com	Recruiter	Hudson	Summit	Ohio	Brian Mako	Matt kaulig	Signed
1315	2022-09-20 13:11	Anonymous (not verified)	173.17.128.203	Leaffilter	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	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.	2022-09-20	Johnny Coker	johnnycoker36@gmail.com	Altoona	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter	support@leafhome.com	Sub contractor	Grimes	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed
1733	2023-07-10 14:30	Anonymous (not verified)	94.188.205.177	Leaf home	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	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.	2023-07-10	Andrew Koske	aokoz_23@outlook.com	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Koske	aokoz_23@outlook.com	None	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed
1545	2023-03-29 20:15	Anonymous (not verified)	94.188.205.176	Leaf Filter LLC	Limited Liability Company	1595 georgetown road hudson ohio 44236	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	Benjamin Joseph Truitt	Bjt1228@yahoo.com	Springville	Linn	Iowa	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewiczi	jnisiewicz@leafhome.com	Regional field recruiter 2	Riverside	Gallatin	Montana	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed
817	2021-12-30 12:58	Anonymous (not verified)	50.80.80.37	Leaf Filter	Limited Liability Company	1595 Georgetown Road Hudson, OH 44236	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.	2021-12-30	Kenneth Van Hook	kennyvanhook1976@gmail.com	Port Byron	Rock Island	IL	Sharon Van Hook	Judy Hoffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	cdunbar@leaffilter.com	Manager	Bettendorf	Scott County	IA	Cody Dunbar	Jordan Nisiewicz	Signed
1993	2024-01-23 07:36	Anonymous (not verified)	94.188.205.168	Leaf Home Solutions LLC	Limited Liability Partnership	1595 Georgetown Road Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-23	Michael Rice	wildblueed@gmail.com	Middle Amana	Iowa	Iowa	Sylvia Rice	Russel Hospadarsky	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Acosta	macosta@leafhome.com	recruiter	Hudson	Summit	Ohio	Sylvia Rice	Russel Hospadarsky	Signed
1623	2023-05-02 14:09	Anonymous (not verified)	94.188.207.226	Leafhome Solutions LLC	Limited Liability Company	1595 Georgetown Road Hudson, Ohio 44236	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.	2023-05-02	Grant Anders Scott	G2designLLC@yahoo.com	Des Moines	Polk	Iowa	Katherine Scott	Brian Yurko	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Yurko	byurko@leafhome.com	Recruiter	Hudson	Summit	Ohio	Katherine Scott	Grant Scott	Signed
1356	2022-11-02 08:21	Anonymous (not verified)	174.215.249.84	Leaf home solutions	Proprietorship	1595 Georgetown Road, Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-02	Micheal Wills	mwills5304@gmail.com	Granger	Polk	IA	Bryanna Wills	Andrew Vannausdle	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryanna Wills	bryannawills725@gmail.com	None	Granger	Polk	IA	Andrew Vannausdle	Micheal Wills	Signed
628	2021-09-01 09:39	Anonymous (not verified)	204.155.61.217	Utzinger Epoxy & Concrete, LLC	Limited Liability Company	1595 Highway 1 Washington, Iowa 52353	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Troy Utzinger	tbutzinger99@kctc.net	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Utzinger	tbutzinger99@kctc.net	owner	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
563	2021-07-08 12:16	Anonymous (not verified)	173.17.250.209	Forest Avenue Outreach	Limited Liability Company	1600 6th Ave DSM 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.	2021-07-08	Maya Bromolson	maya@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
569	2021-07-09 12:18	Anonymous (not verified)	173.17.250.209	Forest Ave Outreach dba Good Vibes Movement	Limited Liability Company	1600 6th Ave DSM 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.	2021-07-09	Ben Spellman	ben@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
332	2020-12-04 10:57	Anonymous (not verified)	66.188.136.150	Ron's Trucking LLC	Limited Liability Company	16007 Oak Avenue, Oak Forrest, IL 60452	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.	2020-12-04	Ronald Clark Jr.	kschumacher@tricorinsurance.com	Oak Forrest	Cook	IL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron's Trucking LLC	kschumacher@tricorinsurance.com	Same	Oak Forrest	Cook	IL	Russell Masartis	Nancy Wortley	Signed
2150	2024-04-15 12:07	Anonymous (not verified)	94.188.205.177	Todd E Holsteen	Proprietorship	16015 Hwy 99, Burlington, IA 52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-28	Todd E Holsteen	kellylanz1967@gmail.com	Burlington	IL	United States	David Steele	Kari Holsteen	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd E Holsteen	kellylanz1967@gmail.com	Self	Burlington	IA	United States	David Steele	Kari Holsteen	Signed
2088	2024-03-12 10:44	Anonymous (not verified)	94.188.207.226	Elmer Henry Vicente Lopez	Proprietorship	1602 Court St Apt 2 Sioux City, IA 51105	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Elmer Henry Vicente Lopez	vicenteelmer33@gmail.com	Sioux City	Woodbury	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Elmer Henry Vicente Lopez	Ronald Halverson	Signed
962	2022-03-09 16:45	Anonymous (not verified)	207.199.231.172	Thomas Whitehead	Proprietorship	1602 Green St Oskaloosa, IA 52577	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.	2022-03-09	Thomas Whitehead	roctomjj@mahaska.org	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Whitehead	roctomjj@mahaska.org	Self	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed
404	2021-02-16 13:30	Anonymous (not verified)	174.198.79.179	Topline Painting llc	Limited Liability Company	1603 e 32nd st Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-16	Michael nunez	toplinepaintingiowa@gmail.com	Des Moines	Polk	Iowa	Jimmy nunez	Jose Nunez	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael nunez	toplinepaintingiowa@gmail.com	Owner	Des moines	Polk	Iowa	Jimmy nunez	Jose nunez	Signed
957	2022-03-08 14:54	Anonymous (not verified)	71.39.227.238	Sharol Williams	Proprietorship	1605 Ash St, Dallas Center, IA 50063	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	Sharol Williams	sharolann48@gmail.com	Dallas Center	Dallas	Iowa	Abbey Luellen	Steve Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Sharol Williams	SharolAnn48@gmail.com	Self	Dallas Center	Dallas	Iowa	Abbey Luellen	Steve Phillips	Signed
50	2020-02-03 14:55	Anonymous (not verified)	173.28.28.57	Silverleaf Capital, LLC	Limited Liability Company	1606 Palmer Court, Parkersburg IA 50665	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.	2020-01-20	Silverleaf Capital, LLC	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Silverleaf Capital, LLC	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
2011	2024-01-31 07:01	Anonymous (not verified)	94.188.205.166	Goede Mechanical	Limited Liability Company	1607 10th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-31	Don Goede	goedemechanical@gmail.com	Harlan	Shelby	Iowa	Dylan Goede	Kallie Goede	Signed	(1) The employer does not elect the employers’ liability coverage.	Don Goede	goedemechanical@gmail.com	Owner	Harlan	Shelby	Iowa	Dylan Goede	Kallie Goede	Signed
1645	2023-05-12 14:48	Anonymous (not verified)	94.188.207.225	VL Drywall LLC	Limited Liability Company	1608 6th Ave SE Cedar Rapids	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	LESLIE LEYVA	lleyva9696@gmail.com	Cedar Rapids	LINN	Iowa	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Leslie Leyva	lleyva9696@gmail.com	Self	Cedar Rapids	Linn	Iowa	Chris Hay	Brad Bower	Signed
437	2021-03-16 18:31	Anonymous (not verified)	38.121.121.16	Thompsen Irrigation	Proprietorship	16086 Missouri Ave Crescent IA 51526	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-17	James R Thompsen	jthom76285@aol.com	Crescent	Pottawattamie	Iowa	Mike Harmon	Ilene Harmon	Signed	(1) The employer does not elect the employers’ liability coverage.	James R Thompsen	jthom76285@aol.com	self	Crescent	Pottawattamie	Iowa	Mike Harmon	Ilene Harmon	Signed
1839	2023-09-12 11:22	Anonymous (not verified)	94.188.205.167	J.S. Reeves Consulting LLC	Limited Liability Company	1610 1st 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.	2023-09-12	joni Sue Reeves	jonisreeves@att.net	Perry	IA	United States	Maggie Rhodes	Barb Butler	Signed	(1) The employer does not elect the employers’ liability coverage.	Joni Sue Reeves	jsreeves67@gmail.com	Same	Perry	IA	United States	Maggie Rhodes	Barb Butler	Signed
1214	2022-07-20 09:51	Anonymous (not verified)	173.23.180.117	Eric Morse	Proprietorship	1610 Hawthorne Ave, Waterloo, IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-09	Eric Richard Morse	ericmorse82@gmail.com	Waterloo	Black Hawk	Iowa	Christine Diane Willis (notary)	Steve Sprague	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Morse	ericmorse82@gmail.com	Self	Waterloo	Black Hawk	Iowa	Christine Diane Willis (notary)	Steven Sprague	Signed
1820	2023-08-28 08:12	Anonymous (not verified)	94.188.205.177	LLAD Services LLC	Limited Liability Company	1611 Esplanade Avenue Davenport IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-28	Austin Lee Terry	austinfarrell92@gmail.com	Davenport	Scott	Iowa	Cody Dunbar	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	JNisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Cody Dunbar	Jordan Loyd	Signed
464	2021-04-07 22:15	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE AND SNOW REMOVAL	Proprietorship	1612 Lomas Circle	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.	2021-04-07	TIM LEE Templeman	nancytempleman@gmail.com	Atlantic	IA	United States	TARA JESSEN	ALFRED WEDE	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	CULLEN AND ASSOCIATES	tammy@cullenins.com	Insurance agent	Atlantic	Cass	Iowa	Tara Jessen	Alfred Wede	Signed
465	2021-04-07 22:24	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE	Proprietorship	1612 Lomas Cr.	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.	2020-11-01	Tim Lee Templemn	nancytempleman@gmail.com	Atlantic	Iowa	United States	Tara Jessen	Alfred Wede	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Lee Templeman	nancytempleman@gmail.com	self	Atlantic	Iowa	Iowa	Tara Jessen	Alfred Wede	Signed
265	2020-09-21 14:41	Anonymous (not verified)	74.84.65.174	Nagol Enterprises	Limited Liability Company	16124 PLEASANT VALLEY DR	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-21	Logan Victor Ante	antelogan@gmail.com	Story CIty	Story	iowa	Brian Wade Warren	Tyler Christian Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Logan Victor Ante	antelogan@gmail.com	Same	Story CIty	IA	IA	Brian Wade Warren	Tyler Christian Thompson	Signed
1566	2023-04-12 08:40	Anonymous (not verified)	94.188.205.169	Sabokwigura Jonathan	Proprietorship	1613 12th Avenue Southeast, Cedar Rapids, IA 52401, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-12	Sabokwigura Jonathan	nzobojo@gmail.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Robert Snyder	Signed

« first
‹ previous
…
6
7
8
9
10
11
12
13
14
…
next ›
last »