Termination of Nonelection of Workers' Compensation or Employers' Liability Coverage
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| # | 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: | Statement 4 Agreement: | 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: | Signed Indication: | Termination Agreement: | 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: | Signed indication: |
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| 7 | 2019-12-10 11:41 | Anonymous (not verified) | 63.153.141.76 | Perkins | Partnership | 217 E hustan Ave Pierre sd 57501 | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2019-12-10 | Reeta Nadeau | reetanadeau802@gmail.com | PIERRE | SD | United States | James McKnight | Skyla dupris | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | Diane London | dlondon@gmail.com | Owner | Ft Pierre | Stanley | Sd | James | Skyla | Signed |
| 8 | 2022-01-14 17:45 | Anonymous (not verified) | 174.198.71.206 | Vertex construction services | Limited Liability Company | 1620 E Diehl Ave | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2022-01-14 | Vertex Construction Services | wdombrowski629@gmail.com | DES MOINES | IA | United States | Billy Dombrowski | Marissa Dombrowski | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | William Michael Dombrowski | wdombrowski629@gmail.com | Owner | DES MOINES | IA | United States | Billy Dombrowski | Marissa Dombrowski | Signed |
| 9 | 2022-09-13 15:01 | Anonymous (not verified) | 192.30.185.233 | Silverio De Los Santos Gonzalez | Proprietorship | 2010 Virginia Street Sioux City, IA 51104 | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2022-09-13 | Silverio De Los Santos Gonzalez | silveriosantos@outlook.com | Sioux City | Woodbury | Iowa | Jeffrey H. McClintock | Timothy J McClintock | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | Jeffrey H McClintock | Jeffm@mcclintockinsurance.com | agent | sioux city | ia | ia | Jeffrey H. McClintock | Timothy J. Mcclintock | Signed |
| 10 | 2023-02-06 17:01 | Anonymous (not verified) | 142.202.101.9 | Polhamus Transfer LLC | Limited Liability Company | 500 N Elm Street Mechanicsville Ia 52306-0027 | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2023-02-06 | Matthew W. Polhamus | Matthewpolhamus@polhamustransferllc.com | Mechanicsville | Cedar | Iowa | Lorraine K Polhamus | Ryan S Steinberg | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | Matthew W. Polhamus | Matthewpolhamus@Polhamustransferllc.com | Self | Mechanicsville | Cedar | Iowa | Lorraine K Polhamus | Ryan S Steinberg | Signed |
| 11 | 2023-08-07 11:57 | Anonymous (not verified) | 94.188.207.230 | Dryseal roofing and Construction | Proprietorship | 390 Olive st Martensdale,IA 50160 | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2023-08-07 | Travis Wayne Tibbits | travistibbits@yahoo.com | Martensdale | Warren | IA | Hannah Marie Tibbits | Chad David Walker | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | Travis Tibbits | travistibbits@yahoo.com | Owner | Martensdale | Warren | IA | Hannah Marie Tibbits | Chad David Walker | Signed |
| 12 | 2023-12-11 16:12 | Anonymous (not verified) | 94.188.207.230 | Cole Plumbing & Heating | Proprietorship | 708 9th St SE, Mason City, IA 50401 | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2023-12-11 | Douglas Cole | dougcoleplumbing@gmail.com | Mason City | Cerro Gordo | Iowa | Melissa Heyden | Tracy Van Sabben | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | Douglas Cole | dougcoleplumbing@gmail.com | self/owner | Mason CIty | Cerro Gordo | Iowa | Melissa Heyden | Tracy Van Sabben | Signed |
| 13 | 2024-03-08 09:37 | Anonymous (not verified) | 94.188.205.177 | Magnum Auto & Transportation | Limited Liability Company | 915 E Walnut St Quasqueton, IA 52326 | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2024-02-29 | Nicole Vanous | magnumautoandtransportation@gmail.com | Quasqueton | Buchanan | IA | Dennis Gardemann | Tressa Walton | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | Nicole Vanous | magnumautoandtransportation@gmail.com | Member | Quasqueton | Buchanan | IA | Dennis Gardemann | Tressa Walton | Signed |
| 14 | 2024-03-08 09:39 | Anonymous (not verified) | 94.188.205.167 | Magnum Auto & Transportation | Limited Liability Company | 915 E Walnut St Quasqueton, IA 52326 | I previously made a nonelection of workers’ compensation or employers’ liability coverage. | I understand that by signing this termination, I will terminate the nonelection of coverage. | I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. | I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. | 2024-02-29 | Brett Vanous | magnumautoandtransportation@gmail.com | Quasqueton | Buchanan | IA | Dennis Gardemann | Tressa Walton | Signed | The employer terminates the prior nonelection the employers’ liability coverage. | Brett Vanous | magnumautoandtransportation@gmail.com | Member | Quasqueton | Buchanan | IA | Dennis Gardemann | Tressa Walton | Signed |