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:	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:
4	2019-11-12 09:06	Anonymous (not verified)	174.71.54.19	M AND J LLC	Limited Liability Company	44100 STATE HIGHWAY 37 Dunlap, IA 51529	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-12	Mark Nichols	mknichols2003@yahoo.com	DUNLAP	Monona	IA	Damon Nichols	Bob Hall	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Nichols	mknichols2003@yahoo.com	Partner	Dunlap	Monona	IA	Damon Nichols	Bob Hall	Signed
5	2019-11-12 09:57	Anonymous (not verified)	174.71.54.19	M AND J LLC	Limited Liability Company	44100 STATE HIGHWAY 37	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-12	M AND J, LLC	mknichols2003@yahoo.com	DUNLAP	MONONA	IA	Damon Nichols	Bob Hall	Signed	(1) The employer does not elect the employers’ liability coverage.	JAMES MUMM	plipichok@yahoo.com	Partner	DUNLAP	MONONA	IA	DAMON NICHOLS	BOB HALL	Signed
6	2019-11-14 13:09	Anonymous (not verified)	69.18.10.115	Sigourney Heating and Air Conditioning LLC	Limited Liability Company	106 E Washington, Sigourney Iowa 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-14	Spencer A Wright	officeshac@gmail.com	Sigourney	Keokuk	Iowa	Darren Diethelm	Myles Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Spencer A Wright	officeshac@gmail.com	Owner	Sigourney	Keokuk	Iowa	Darren Diethelm	Myles Miller	Signed
7	2019-11-15 12:26	Anonymous (not verified)	173.17.129.166	Thomas C. Davis	Proprietorship	3509 Franklin Ave, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-15	Thomas C. Davis III	thomas.davis.iii@gmail.com	Des Moines	Polk	Iowa	Jared Vincent	Kevin Corn	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas C. Davis III	thomas.davis.iii@gmail.com	Employer	Des Moines	Polk	Iowa	Jared Vincent	Kevin Corn	Signed
8	2019-12-13 12:18	Anonymous (not verified)	173.18.3.76	Knight Electric, LLC	Limited Liability Company	200 E Aurora Ave, Des Moines, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-13	Ryan Lewis	ryan@knightelectric.biz	Des Moines	Polk	Iowa	Angie Kinsey	Jon Stetzel	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Lewis	ryan@knightelectric.biz	Member/Owner	Des Moines	Polk	Iowa	Angie Kinsey	Jon Stetzel	Signed
9	2019-12-16 11:33	Anonymous (not verified)	50.81.115.85	Travis Garrett and Caleb Elliott	Partnership	P.O. Box 55, Boone, IA 50036	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-16	Travis Garrett	onethird4599@gmail.com	Boone	Boone	IA	Katie Frame	Jessica Carroll	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Garrett & Caleb Elliott	onethird4599@gmail.com	Owner	Boone	Boone	IA	Katie Frame	Jessica Carroll	Signed
10	2019-12-16 11:35	Anonymous (not verified)	50.81.115.85	Travis Garrett and Caleb Elliott	Partnership	P.O. Box 55, Boone, IA 50036	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-16	Caleb Elliott	onethird4599@gmail.com	Boone	Boone	IA	Katie Frame	Jessica Carroll	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Garrett & Caleb Elliott	onethird4599@gmail.com	Owner	Boone	Boone	IA	Katie Frame	Jessica Carroll	Signed
11	2019-12-17 19:46	Anonymous (not verified)	50.83.188.192	B & B Construction	Proprietorship	2463 93rd Avenue, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-17	Louis I. Maxwell	brockbrooke2463@yahoo.com	Norwalk	IA	United States	Hope Winegardner	Yvonne Ginther	Signed	(1) The employer does not elect the employers’ liability coverage.	Louis Maxwell	brockbrooke2463@yahoo.com	Owner	Norwalk	IA	United States	Hope Winegardner	Yvonne Ginther	Signed
12	2019-12-17 19:54	Anonymous (not verified)	50.83.188.192	B & B Construction	Proprietorship	2463 93rd Avenue Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-17	Brock A Maxwell	brock246393@gmail.com	Des Moines	IA	United States	Hope Winegardner	Yvonne Ginther	Signed	(1) The employer does not elect the employers’ liability coverage.	Brock A Maxwell	brock246393@gmail.com	Owner	Des Moines	POlK	Iowa	Yvonne Ginther	Hope Winegardner	Signed
13	2019-12-30 14:27	Anonymous (not verified)	173.24.181.211	TERRY GALBRAITH DBA HUNEYDEW CONSTRUCTION	Proprietorship	706 SUNSHINE RUN ARNOLDS PARK IA 51331	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-27	TERRY GALBRAITH	CT_INSPECTIONS@MEDIACOMBB.NET	ARNOLDS PARK	DICKINSON	IA	KRIS WALKER	JOE LORING	Signed	(1) The employer does not elect the employers’ liability coverage.	TERRY GALBRAITH	CT_INSPECTIONS@MEDIACOMBB.NET	SELF	ARNOLDS PARK	DICKINSON	IA	JOE LORING	KRIS WALKER	Signed
14	2019-12-30 17:22	Anonymous (not verified)	173.20.51.69	Rotten Love LLC	Limited Liability Company	1101 Valentine Drive, Dubuque Iowa 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-01-01	john rettenmeier	jrettenmeier@gmail.com	dubuque	Dubuque	iowa	Carolyn Schmid	Joe Rettenmeier	Signed	(1) The employer does not elect the employers’ liability coverage.	Carolyn Schmid	jrettenmeier@gmail.com	owner	Dubuque	Dubuque	iowa	John Rettenmeier	John Rettenmeier	Signed
15	2019-12-30 18:13	Anonymous (not verified)	104.166.243.52	Matt Moore	Proprietorship	8450 Hickman Road #15C	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-30	Matt Moore	mljm2016@outlook.com	Clive	Iowa	Iowa	Tom Onnen	James Buffington	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Moore	mljm2016@outlook.com	Subcontractor	Urbandale	IOWA	United States	Tom Onnen	James Buffington	Signed
16	2019-12-31 08:54	Anonymous (not verified)	70.184.208.208	J & D Transportation	Proprietorship	1125 Lew Ross Road Council Bluffs, IA 51501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-31	Clarence Cecil Stogdill	jack@jdmmtrucking.com	Council Bluffs	Iowa	United States	Mickey Jerome Stogdill	Laurie Jo Stogdill	Signed	(1) The employer does not elect the employers’ liability coverage.	Clarence Cecil Stogdill	jack@jdmmtrucking.com	owner-same person	Council Bluffs	Iowa	United States	Mickey Jerome Stogdill	Laurie Jo Stogdill	Signed
17	2019-12-31 09:24	Anonymous (not verified)	72.35.186.80	Grgurich Dozing & Tiling, LLC	Partnership	PO Box 131, Williamson, IA 50272	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-31	Seth Grgurich	mcbroomt15@gmail.com	Williamson	Lucas	Iowa	Eric Curran	Stacy Smyser	Signed	(1) The employer does not elect the employers’ liability coverage.	Seth Grgurich	mcbroomt15@gmail.com	Partner	Williamson	Lucas	Iowa	Eric Curran	Stacy Smyser	Signed
19	2019-12-31 16:29	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Amar Music	amarmusic01@gmail.com	Owner	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed
20	2019-12-31 16:36	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Omer Okic	ultimate.exteriors@gmail.com	Owner	Des Moines	Polk	IA	Sefik Music	Amara Crncevic	Signed
21	2020-01-01 18:16	Anonymous (not verified)	72.35.186.80	Jerry Arnold	Proprietorship	1426 25th St, Humeston, IA 50123	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.	2020-01-01	Jerry Arnold	LLArnold62@gmail.com	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Arnold	LLArnold62@gmail.com	Self	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed
22	2020-01-02 14:52	Anonymous (not verified)	173.17.129.166	Dan & Sarah Gudenkauf	Proprietorship	3277 180th Ave, Ryan, IA 52330	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-02	Sarah Gudenkauf	dandselectricmotor@gmail.com	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Gudenkauf	dandselectricmotor@gmail.com	Owner	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed
23	2020-01-02 14:54	Anonymous (not verified)	173.17.129.166	Dan Gudenkauf	Proprietorship	3277 180th Ave, Ryan, IA 52330	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-02	Dan Gudenkauf	dandselectricmotor@gmail.com	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Gudenkauf	dandselectricmotor@gmail.com	Owner	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed
24	2020-01-03 12:41	Anonymous (not verified)	63.152.13.239	Eden Plumbing LLC TJ Eden	Limited Liability Company	502 Packwaukee Street New Hartford, IA 50660	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.	2020-01-03	TJ Eden	edentj@aol.com	New Hartford	IA	United States	Ann Robinson	Nate Schmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	PDCM Insurance- Nate Schmidt	NSCHMIDT@PDCM.COM	Member	New Hartford	Butler	Iowa	Ann Robinson	Nate Schmidt	Signed
25	2020-01-03 13:09	Anonymous (not verified)	74.84.121.206	Raymond Jones	Proprietorship	P O Box 682 Monona IA 52159	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-29	Raymond Jones	darrele@ciains.biz	Monona	Clayton	Iowa	Darrel J Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel J Elsbernd	darrele@ciains.biz	insurance agent	Lime Springs	Howard	Iowa	Darrel J Elsbernd	Chris Fye	Signed
26	2020-01-04 17:23	Anonymous (not verified)	45.53.67.52	Gary De Jager	Limited Liability Company	417 florida Ave NW Orange City Iowa 51041	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.	2020-01-04	Gary Dean De Jager	mightyspear60@yahoo.com	Orange City	Souix	Iowa	Brody Dean De Jager	Tyler Ray De Jager	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Dean De Jager	mightyspear60@yahoo.com	owner	Orange City	souix	Iowa	Brody Dean De Jager	Tyler Ray De Jager	Signed
27	2020-01-06 09:17	Anonymous (not verified)	24.149.10.119	Miss Wonderful LLC	Limited Liability Company	216 Main St Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	Ann Eastman	misswonderful216@gmail.com	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed	(1) The employer does not elect the employers’ liability coverage.	Ann Eastman	misswonderful216@gmail.com	Owner	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed
28	2020-01-06 13:39	Anonymous (not verified)	108.178.203.226	MULLIS CATTLE LLC	Limited Liability Company	2506 155TH ST, EARLVILLE IA 52041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	NICOLAS MULLIS	JAMES@CIOIA.COM	GREELEY	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed	(1) The employer does not elect the employers’ liability coverage.	NICOLAS MULLIS	JAMES@CIOIA.COM	OWNER	GREELEY	DELAWARE	IA	MERRI MOSER	BRITTANY LANSING	Signed
29	2020-01-06 13:44	Anonymous (not verified)	108.178.203.226	MULLIS CATTLE LLC	Limited Liability Company	2506 155TH ST, EARLVILLE IA 52041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	DAVID MULLIS	JAMES@CIOIA.COM	EARLVILLE	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed	(1) The employer does not elect the employers’ liability coverage.	DAVID MULLIS	JAMES@CIOIA.COM	OWNER	EARLVILLE	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed
30	2020-01-07 08:34	Anonymous (not verified)	199.10.5.7	Data Information Management LLC	Limited Liability Company	703 Bluff St Dubuque IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-07	Stephen M Schauff	steve@caricomm.com	Dubuque	Iowa	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher R Broessel	chris@caricomm.com	Partner	Dubuque	Iowa	IA	Janet L Schauff	Morris P schauff	Signed
31	2020-01-07 08:37	Anonymous (not verified)	199.10.5.7	Data Information Management LLC	Limited Liability Company	703 Bluff St Dubuque IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-07	Christopher R Broessel	chris@caricomm.com	Dubuque	Dubuque	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen M schauff	steve@caricomm.com	Partner	Dubuque IA	Dubuque	Iowa	Janet L schauff	Morris P Schauff	Signed
32	2020-01-08 08:31	Anonymous (not verified)	199.120.118.90	BOBCATS LLC	Limited Liability Company	1860 505TH ST LINN GROVE IOWA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-18	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	OWNER	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed
33	2020-01-09 15:57	Anonymous (not verified)	173.28.28.57	FALCON PRIDE PROPERTIES LLC	Limited Liability Company	1401 HWY 57 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.	2019-12-13	TODD THOMAS	todd@wimcoach.com	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed	(1) The employer does not elect the employers’ liability coverage.	TODD THOMAS	todd@wimcoach.com	SELF	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed
34	2020-01-10 15:56	Anonymous (not verified)	74.84.121.206	Milferd Loewen	Proprietorship	6568 Hwy 63, Lime Springs, IA 52155	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.	2020-01-10	Milferd Loewen	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel J. Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Milferd Loewen	darrele@ciains.biz	self	Lime Springs	Howard	Iowa	Darrel J. Elsbernd	Chris Fye	Signed
35	2020-01-13 13:23	Anonymous (not verified)	173.28.28.57	Milkhouse Market, LLC	Limited Liability Company	911 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-30	MARY MEYER	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	MARY MEYER	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
36	2020-01-15 13:26	Anonymous (not verified)	173.28.28.57	Shirley Pepples	Proprietorship	206 4th Street, 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.	2020-01-14	Shirley Pepples	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Shirley Pepples	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
37	2020-01-16 15:26	Anonymous (not verified)	173.24.236.134	Eric Krueger	Proprietorship	406 NE Oak Dr. Ankeny, IA 50021	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.	2020-01-16	Eric Lucas Krueger	erickrugs@gmail.com	Ankeny	Polk	Iowa	Emily Marie Krueger	Roberty William Krueger	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Krueger	erickrugs@gmail.com	self	Ankeny	Polk	Iowa	Emily Marie Krueger	Robert William Krueger	Signed
38	2020-01-18 12:15	Anonymous (not verified)	206.109.174.199	BJS Frenchies, LLC	Limited Liability Company	20081 Highway J 46 Centerville Iowa 52544	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	J. Jamie Tracy	jamiespuppies@yahoo.com	Centerville	Appanoose	Iowa	Misty O'Hair	Casey Leach	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce E Tracy	jamiespuppies@yahoo.com	Husband and Co Owner	Centerville	Appanoose	Iowa	Misty O'Hair	Casey Leach	Signed
39	2020-01-19 11:00	Anonymous (not verified)	75.163.84.145	Allen L Bryen	Proprietorship	2609 Madison St Bellevue NE 68005	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.	2020-01-19	Allen Lee Bryen	Allen.Bryen@yahoo.com	Bellevue	Sarpy	Nebraska	Jeffrey Coats	Donald Coats	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen L Bryen	Allen.Bryen@yahoo.com	Self	Bellevue	Sarpy	Nebraska	jeffrey Coats	Donald Coats	Signed
40	2020-01-19 13:20	Anonymous (not verified)	167.142.82.171	Arganbright Land Improvement LLC	Limited Liability Company	2440 Redwood Ave. Guthrie Center, IA 50115	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.	2020-01-19	Josh Arganbright	josh@arganbrightlandimp.com	Guthrie Center	Guthrie	IA	Kim Bauer	Tom Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Arganbright	josh@arganbrightlandimp.com	self	Guthrie Center	Guthrie	IA	Kim Bauer	Tom Smith	Signed
41	2020-01-20 14:26	Anonymous (not verified)	173.24.181.211	BARBARA HOOGEVEEN	Proprietorship	304 MILL POND RD, ROCK RAPIDS, IA 51246	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	BARBARA HOOGEVEEN	MCGILLH@MTCNET.NET	ROCK RAPIDS	LYON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	BARABARA HOOGEVEEN	MCGILLH@MTCNET.NET	OWNER	ROCK RAPIDS	LYON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
42	2020-01-24 12:26	Anonymous (not verified)	173.24.181.211	MIKE EDDY	Proprietorship	PO BOX 437 OKOBOJI, IA 51355	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.	2020-01-22	MIKE EDDY	joel@walkerinsuranceia.com	OKOBOJI	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	MIKE EDDY	JOEL@WALKERINSURANCEIA.COM	OWNER	OKOBOJI	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
43	2020-01-27 09:23	Anonymous (not verified)	71.199.85.251	ATW Training	Limited Liability Company	4414 114th Street, Urbandale Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-25	Heather Hampton Cooper	hcooper1@comcast.net	Saint Augustine	Saint Johns	Florida	Terry Lee Cooper	Stacy Thatcher	Signed	(1) The employer does not elect the employers’ liability coverage.	Lynn Roberts	Lynne@atwtraining.com	HR	Des Moines	Polk	Iowa	Cathy Belmont	Mark Purcell	Signed
44	2020-01-28 12:55	Anonymous (not verified)	173.24.181.211	AMANDA FIEDLER	Proprietorship	10 5TH AVE NW FOSTORIA, IA 51340	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.	2020-01-28	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	FOSTORIA	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	OWNER	FOSTORIA	CLAY	IA	JOSPH THOMAS LORING	TAMI SUE KLEIN	Signed
45	2020-01-28 16:13	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Adin Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Lutfija Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
47	2020-01-28 16:35	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	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.	2020-01-27	Sabahudin Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Adin Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
48	2020-01-29 13:52	Anonymous (not verified)	97.64.170.98	DARIN J. KESSLER	Proprietorship	1236 25TH ST AMES, IA 50010	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.	2020-01-29	DARIN J. KESSLER	darinjkessler@gmail.com	AMES	STORY	IOWA	HEATHER DIANNE LANNING	JENNY ANN ARENDS	Signed	(1) The employer does not elect the employers’ liability coverage.	DARIN J. KESSLER	darinjkessler@gmail.com	SELF	AMES	STORY	IOWA	HEATHER DIANNE LANNING	JENNY ANN ARENDS	Signed
49	2020-01-31 12:53	Anonymous (not verified)	74.84.121.206	Cody Kleppe	Proprietorship	1891 337th St Decorah IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Cody Kleppe	darrele@ciains.biz	Decorah	Winneshiek	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Decorah	Winneshiek	Iowa	Chris Fye	Darrel Elsbernd	Signed
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
51	2020-02-04 10:31	Anonymous (not verified)	173.28.28.57	Sister Style, LLC	Limited Liability Company	211 3rd Street, 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.	2020-01-23	Lisa Ellis	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Ellis	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
52	2020-02-04 10:35	Anonymous (not verified)	173.28.28.57	Sister Style, LLC	Limited Liability Company	211 3rd Street, 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.	2020-01-23	Amanda Jorgenson	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Amanda Jorgenson	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
53	2020-02-06 11:09	Anonymous (not verified)	65.100.22.228	Bostian Captioning Service, Inc.	Proprietorship	712 8th Avenue NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-06	Dana Bostian	danabostian@msn.com	Oelwein	IA	United States	Lynne Koch	Billie Winters	Signed	(1) The employer does not elect the employers’ liability coverage.	Dana Bostian	danabostian@msn.com	President of Proprietorship	Oelwein	IA	United States	Lynne Koch	Billie Winters	Signed
54	2020-02-06 14:18	Anonymous (not verified)	173.28.28.57	Dale Hansman dba Klinkenborg Hansmann Law Office	Proprietorship	1201 Hwy 57, 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.	2020-01-14	Dale Hansmann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Hansmann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
55	2020-02-07 15:14	Anonymous (not verified)	204.153.176.73	J*M Fuels, LLC	Limited Liability Company	600 W Bremer Avenue, Waverly IA 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-07	Matt Johnson	mattjohnson7555@gmail.com	Jackson TWP	Butler	Iowa	Ty Burke	Lori Frerichs	Signed	(1) The employer does not elect the employers’ liability coverage.	Tylor Burke	tburke@acceladvantage.com	Agent	Waverly	IA	United States	Tony Pollastrini	Lori Frerichs	Signed
56	2020-02-07 15:17	Anonymous (not verified)	204.153.176.73	J*M Fuels, LLC	Limited Liability Company	600 W Bremer Avenue, Waverly IA 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-07	Jim Johnson	mattjohnson7555@gmail.com	Jackson TWP	Butler	Iowa	Ty Burke	Lori Frerichs	Signed	(1) The employer does not elect the employers’ liability coverage.	Ty Burke	tburke@acceladvantage.com	Agent	Waverly	IA	United States	Tony Pollastrini	Lori Frerichs	Signed
57	2020-02-10 15:33	Anonymous (not verified)	198.167.182.164	AllEnhancements LLC	Limited Liability Company	1122 Woodland Ln, LeClaire, IA 52753	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Brett Allen	allenhancementsllc@outlook.com	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Allen	allenhancementsllc@outlook.com	Managing Member	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed
58	2020-02-10 21:18	Anonymous (not verified)	75.162.11.63	Moni tile Services llc	Limited Liability Company	2207 E Walnut St des Moines iowa 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.	2020-02-01	Monica M Sandoval	Mjsandoval20@yahoo.com	Des Moines	Polk	United States	Cassie Ann bentz	James wesley harkert	Signed	(1) The employer does not elect the employers’ liability coverage.	Moni tile services llc	Mjsandoval20@yahoo.com	Self	Des Moines	Polk	Iowa	Cassie Ann bentz	James wesley harkert	Signed
59	2020-02-11 11:34	Anonymous (not verified)	198.167.182.164	Besch Electric LLC	Limited Liability Company	317 Sycamore St, Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-03	Daniel Besch	beschd@hotmail.com	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Besch	beschd@hotmail.com	Managing Member	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed
60	2020-02-12 10:10	Anonymous (not verified)	198.167.182.164	Sara Torres	Proprietorship	419 Lilac St, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-11	Sara Torres	skb_blue08@hotmail.com	Tiffin	Johnson	Iowa	Steven J Fishman	E. Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sara Torres	skb_blue08@hotmail.com	Owner	Tiffin	Johnson	Iowa	Steven J Fishman	E Dyan Kriener	Signed
61	2020-02-13 08:44	Anonymous (not verified)	71.28.216.94	Cyclone Captioning, Inc	Proprietorship	8866 W 122nd Street N, Mingo, IA 50168	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-13	Holli L. Schneider	Hlschneid87@gmail.com	Mingo	Jasper	IA	Dan Herrin	Minda Dearden	Signed	(1) The employer does not elect the employers’ liability coverage.	Holli Schneider	hlschneid87@gmail.com	President of Proprietorship	Mingo	Jasper	IA	Dan Herrin	Minda Dearden	Signed
62	2020-02-17 06:55	Anonymous (not verified)	173.31.111.29	Pa's Construction LLC	Limited Liability Company	2350 Glass Rd NE, Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-17	Gregory Daniel Saunders	gsaunders.pas@gmail.com	CEDAR RAPIDS	IOWA	United States	Laura Sturm	Chad Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Saunders	dan2112411@yahoo.com	Owner	Cedar Rapids	Linn	Iowa	Walt Cheney	Mike Broghammer	Signed
63	2020-02-17 16:05	Anonymous (not verified)	173.17.12.213	ANA GARCIA GONZALEZ	Limited Liability Company	4023 14TH ST DES MOINES IOWA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-17	Ana Garcia Gonzalez	gjeanettegonzalez@gmail.com	DES MOINES	POLK	IOWA	LUZ SAUCEDA	SANDRA ISABEL SAUCEDA	Signed	(1) The employer does not elect the employers’ liability coverage.	ANA GARCIA GONZALEZ	GJEANETTEGONZALEZ@GMAIL.COM	SELF	DES MOINES	POLK	IA	LUZ SOTELO SAUCEDO	SANDRA ISABEL SAUCEDA	Signed
64	2020-02-18 10:02	Anonymous (not verified)	198.167.182.164	Elite Electrical Service LLC	Limited Liability Company	2035 Lynncrest Dr, Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Sean Brogan	brogan_sean@hotmail.com	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Brogan	brogan_sean@hotmail.com	Managing Member	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
65	2020-02-18 15:44	Anonymous (not verified)	70.58.180.91	TD & I CABLE MAINTENANCE INC.	Proprietorship	P.O. BOX 266 LAKELAND MN. 55043	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	FREDERICK W GREEN	FREDGREENCONSTRUCTION@YAHOO.COM	DES MOINES	POLK	IOWA	KATHYRN EILEEN WILLIAMSON	MICHAEL BOYD WILLIAMS	Signed	(1) The employer does not elect the employers’ liability coverage.	LIZZY SHEPARD	LIZZYSHEPARD@TDICABLE.COM	SUBCONTRACTOR	LAKELAND	WASHINGTON	MINNESOTA	KATHRYN EILEEN WILLIAMSON	MICHAEL BOYD WILLIAMS	Signed
66	2020-02-19 08:48	Anonymous (not verified)	170.232.227.246	CRS Inc	Proprietorship	1442 3rd Ave SW Belmond, IA 50421	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	Rebecca Gardner	beckygard1018@gmail.com	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed	(1) The employer does not elect the employers’ liability coverage.	Rebecca Gardner	beckygard1018@gmail.com	Consultant	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed
67	2020-02-19 10:16	Anonymous (not verified)	198.167.182.164	AWF579 LLC	Limited Liability Company	13 Lynden Dr NE, Iowa City, IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Managing Member	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
68	2020-02-19 12:00	Anonymous (not verified)	198.14.241.59	SIERRA ROOFING LLC	Limited Liability Company	909 N ELM ST WEST LIBERTY IA 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	ABRAHAM GRANJENO	SIERRA89@GMAIL.COM	WEST LIBERTY	MUSCATINE	IOWA	JOSE SALGADO	ALEJANDRIA FRAUSTO	Signed	(1) The employer does not elect the employers’ liability coverage.	ABRAHAM GANJENO	SIERRA89@GMAIL.COM	OWNER	WEST LIBERTY	MUSCATINE	IOWA	JOSE SALGADO	ALEJANDRIA FRAUSTO	Signed
69	2020-02-19 15:58	Anonymous (not verified)	198.14.241.59	MORENOS C ROOFING LLC	Limited Liability Company	2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed	(1) The employer does not elect the employers’ liability coverage.	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	OWNER	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed
70	2020-02-19 19:30	Anonymous (not verified)	173.25.39.58	Central Iowa Portable Welding	Limited Liability Company	708 S Main St. Woodward Ia, 50276	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	Eric Lendt	Eric@weldiowa.com	Woodward	America	IA	Chris Lendt	Central Iowa Portable Welding	Signed	(1) The employer does not elect the employers’ liability coverage.	Central Iowa Portable Welding	Eric@weldiowa.com	Himself	woodward	American	IA	Central Iowa Portable Welding	Central Iowa Portable Welding	Signed
71	2020-02-21 05:24	Anonymous (not verified)	70.100.107.197	CRS Inc.	Proprietorship	1442 3rd Ave SW	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	Monica Christensen	monicalchristensen@gmail.com	Belmond	Wright	Iowa	Jessica Tempus	Dawn Butler	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Christensen	monicalchristensen@gmail.com	Consultant	Belmond	Iowa	United States	Dawn Butler	Jessica Tempus	Signed
72	2020-02-21 09:43	Anonymous (not verified)	98.18.174.183	Forrest E. Whitford DVM LLC	Limited Liability Company	P.O. Box 120 - 507 Washington Street, Volga, IA 52077	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-21	Forrest E. Whitford, DVM LLC	gfw54@hotmail.com	Volga, IA	Clayton	Iowa	Glenna Whitford	Pam Vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Forrest E. Whitford, DVM LLC	gfw54@hotmail.com	self	Volga	Clayton	Iowa	Glenna Whitford	Pam Vaske	Signed
73	2020-02-21 13:44	Anonymous (not verified)	192.30.185.233	Viejos Masnry construction LLC	Limited Liability Company	1708 Villa Ave. Sioux City IA 51103	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-13	Oscar Castro Ramirez	veijosconstruction@gmail.com	Sioux City	Woodbury	Iowa	JEFFREY H MCCLINTOCK	Nancy Fleming	Signed	(1) The employer does not elect the employers’ liability coverage.	Viejos Masonry Construction LLC	veijosconstruction@gmail.com	Owner/President	SIOUX CITY	Woodbury	Iowa	Nancy Fleming	Jeffrey Hugh McClintock	Signed
74	2020-02-24 15:00	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	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.	2020-01-01	Ramiro Jurado Gomez	Liberty21424@gmail.com	Des Moines	Polk	IA	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Valerie Cramer	cramerlaw@halousa.com	Attorney	Des Moines	Polk	Iowa	David Murray	Sara McGinnis	Signed
75	2020-02-24 15:03	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	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.	2020-01-01	Ramiro Jurado Bucio	Liberty21424@gmail.com	des moines	Polk	Iowa	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Valerie Cramer	cramerlaw@halousa.com	Attorney	Des Moines	Polk	Iowa	David Murray	Sara McGinnis	Signed
76	2020-02-24 15:05	Anonymous (not verified)	97.64.133.18	Sky Roofing	Partnership	1332 Idaho St., Des Moines, IA 50316	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.	2020-01-01	Angel Jurado	Liberty21424@gmail.com	des moines	Polk	Iowa	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Cramer Law PLC	cramerlaw@halousa.com	Attorney	Polk	Polk	Iowa	Sara Mc Ginnis	David Murray	Signed
77	2020-02-24 15:07	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	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.	2020-01-01	Victor Jurado	Liberty21424@gmail.com	des moines	Polk	Iowa	David Murray	Valerie Cramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Cramer Law PLC	Liberty21424@gmail.com	Attorney	DES MOINES	POlk	Iowa	David Murray	Sara McGinnis	Signed
78	2020-02-25 09:35	Anonymous (not verified)	65.127.131.118	Rey Construction, LLC	Proprietorship	3317 Scott Ave Des Moines, iowa 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.	2020-02-02	Juan Raymundo Hernandez	reyano43@gmail.com	Des Moines	polk	iowa	Rigoberto Mayorga	Y Bounv Quang	Signed	(1) The employer does not elect the employers’ liability coverage.	Preferred Interior Construction INC dba PIC INC	deb@piciowa.com	PIC, INC-contractor, Rey Construction, LLC-subcontractor	Altoona	IA	United States	Martin Pinon	Evan Bianchi	Signed
79	2020-02-25 17:28	Anonymous (not verified)	66.43.239.175	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-25	Tamara Glendenning	lanceandabby@wccta.net	Davis Junction	Ogle	Il	Dena M. Anderson	Shelly Brus	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Glendenning	lanceandabby@wccta.net	President	Churdan	Greene	IA	Dena M Anderson	Shelly Brus	Signed
80	2020-02-25 17:29	Anonymous (not verified)	66.43.239.175	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-25	Terry Glendenning	lanceandabby@wccta.net	Davis Junction	Ogle	Il	Dena M. Anderson	Shelly Brus	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Glendenning	lanceandabby@wccta.net	President	Churdan	Greene	IA	Dena M Anderson	Shelly Brus	Signed
81	2020-02-25 17:31	Anonymous (not verified)	66.43.239.175	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-25	Abby Glendenning	lanceandabby@wccta.net	Churdan	Greene	Iowa	Dena M. Anderson	Shelly Brus	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Glendenning	lanceandabby@wccta.net	President	Churdan	Greene	IA	Dena M Anderson	Shelly Brus	Signed
82	2020-02-25 17:32	Anonymous (not verified)	66.43.239.175	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-25	Lance Glendenning	lanceandabby@wccta.net	Churdan	Greene	Iowa	Dena M. Anderson	Shelly Brus	Signed	(1) The employer does not elect the employers’ liability coverage.	Abby Glendenning	lanceandabby@wccta.net	Officer	Churdan	Greene	IA	Dena M Anderson	Shelly Brus	Signed
83	2020-02-28 12:55	Anonymous (not verified)	204.16.58.27	Baltes Trucking LLC	Limited Liability Company	203 N Gilmore Ave New Hampton IA 50659	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-28	Clinton Lee Baltes	clintbaltes@gmail.com	New Hampton	Chickasaw	Iowa	Tammy Robinson	Richard Kramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Clinton Lee Baltes	clintbaltes@outlook.com	Owner	New Hampton	Chickasaw	Iowa	Tammy Robinson	Richard Kramer	Signed
84	2020-02-28 15:30	Anonymous (not verified)	198.167.182.164	Rid-A-Bird Inc.	Limited Liability Company	3116 Friendship St. Iowa City IA 52245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-28	Keith Wilson	kwilson@windowgenie.com	Iowa City	Johnson	Iowa	Dyan Kriener	Marcia A Colvin	Signed	(1) The employer does not elect the employers’ liability coverage.	Keith Wilson	kwilson@windowgenie.com	Managing member	Iowa City	Johnson	Iowa	Dyan Kriener	Marcia A Colvin	Signed
85	2020-03-09 08:17	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-05	Jessi Kettenacker	jessi@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessi Kettenacker	jessi@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
86	2020-03-09 08:19	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-05	Cande Coulter	cande@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Candy Coulter	cande@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
87	2020-03-11 15:42	Anonymous (not verified)	50.105.78.41	Al's Aerial Spraying, LLC	Limited Liability Company	3473 N Shepardsville Rd, Ovid MI 48866	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-11	Albert Edward Schiffer	Al400@aol.com	Ovid	Cliinton	Michigan	Seth Alexander	Nicholas Crofoot	Signed	(1) The employer does not elect the employers’ liability coverage.	Albert Edward Schiffer	Al400@aol.com	Boss	Ovid	Clinto	Michigan	Nicholas Crofoot	Nicholas Crofoot	Signed
88	2020-03-11 15:45	Anonymous (not verified)	50.105.78.41	Al's Aerial Spraying, LLC	Limited Liability Company	3473 N Shepardsville Rd, Ovid MI 48866	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.	2021-03-11	Michael Schiffer	Mike502B@aol.com	Ovid	Clinton	MI	Seth Alexander	Nicholas Crofoot	Signed	(1) The employer does not elect the employers’ liability coverage.	Albert Schiffer	Al400@aol.com	employee	Ovid	Clinton	Michigan	Seth Alexander	Nicholas Crofoot	Signed
89	2020-03-13 12:41	Anonymous (not verified)	216.96.113.16	B’s Sweet Treats	Proprietorship	123 E Marion St. Sigourney IA 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-13	Brandi Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	IA	Brandi	Brandi	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandi Wehr	brndwehr54@hotmail.com	Same	Sigourney	Keokuk	IA	Brandi	Brandi	Signed
90	2020-03-13 15:44	Anonymous (not verified)	173.24.190.134	Heath Householder	Limited Liability Company	2 N Huron Street, Emmetsburg IA 50536	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.	2020-01-07	Heath Householder	heath679@live.com	Emmetsburg	Palo Alto	Iowa	Scott Wirtz	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Householder	heath679@live.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Scott Wirtz	Candie Clark	Signed
91	2020-03-13 15:51	Anonymous (not verified)	173.24.190.134	Small Town RV, LLC	Limited Liability Company	112 Miller 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.	2020-03-09	Heath Sabin	sales@smalltownrv.com	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Sabin	sales@smalltownrv.com	Member of LLC	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed
92	2020-03-13 15:53	Anonymous (not verified)	173.24.190.134	Tammy Sabin	Limited Liability Company	112 Miller 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.	2020-03-09	Tammy Sabin	sales@smalltownrv.com	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Tammy Sabin	sales@smalltownrv.com	Member of LLC	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed
93	2020-03-16 08:01	Anonymous (not verified)	174.217.14.119	DOUBLE J CONTRACTING LLC	Limited Liability Company	18693 335TH LN, EARLHAM, IA 50072	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-16	JOSHUA D OSCARSON	double-j-llc@outlook.com	EARLHAM	DALLAS	IOWA	Tim Hudson	Kevin Gomez	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas Oscarson	double-j-llc@outlook.com	Business Manager	Earlham	Dallas	Iowa	Tim Hudson	Kevin Gomez	Signed
94	2020-03-18 13:18	Anonymous (not verified)	174.243.114.80	Sogard Excavating	Limited Liability Company	2374 380th St, Jewell, IA 50130	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-18	Jon A Sogard	jsogard22@gmail.com	Jewell	Hamilton	IA	Fallon Sogard	Julee Lund	Signed	(1) The employer does not elect the employers’ liability coverage.	Sogard Excavating LLC	jsogard22@gmail.com	owner	Jewell	Hamilton	IA	Fallon Sogard	Julee Lund	Signed
95	2020-03-18 14:47	Anonymous (not verified)	173.24.186.251	Layton C. Vick II dba Layton's Backhoe Service	Proprietorship	PO Box 652 / Spirit Lake, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-18	Layton Clarence VIck II	lcvii2@gmail.com	Lake Park	Dickinson	Iowa	Daniel Reimers	Marcus VanKleek	Signed	(1) The employer does not elect the employers’ liability coverage.	Layton C. Vick II	lcvii2@gmail.com	Owner	Lake Park	Dickinson	Iowa	Daniel Reimers	Marcus VanKleek	Signed
96	2020-03-19 12:11	Anonymous (not verified)	173.24.181.211	JENSEN GROUP LP	Limited Liability Partnership	PO BOX 721 ARNOLDS PARK, IA 51331	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-18	MICHAEL JENSEN	Michael@BuyGreatLakes.com	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	MICHAEL JENSEN	JOEL@WALKERINSURANCE.COM	PARTNER	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
97	2020-03-21 12:05	Anonymous (not verified)	173.22.82.137	JHK Construction LLC	Limited Liability Company	6203 Casey Court NE Cedar Rapids, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-21	Edward Charles Loehr	jhkconstruction10@gmail.com	Cedar Rapids	Linn County	Iowa	Brandon Peters	Mandy Mason	Signed	(1) The employer does not elect the employers’ liability coverage.	Edward Charles Loehr	jhkconstruction10@gmail.com	Owner	6203 Casey Court NE	Linn County	Iowa	Brandon Peters	Mandy Mason	Signed
98	2020-03-23 15:07	Anonymous (not verified)	65.120.236.250	Cross Roads Logistics, LLC	Limited Liability Company	3103 21st St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-23	Mark Alan Cross	rcreek2016@gmail.com	Davenport	IA	IA	Lori Ann Cross	Barbara A Deering	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Alan Cross	rcreek2016@gmail.com	President/Owner	Davenport	IA	IA	Lori Ann Cross	Barbara A Deering	Signed
99	2020-03-23 16:47	Anonymous (not verified)	216.96.116.78	B’s Sweet Treats	Proprietorship	21484 196th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-23	Brandi Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	IA	Erik Wehr	Brenda Workman	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandi Wehr	brndwrhr54@hotmail.com	Self	Sigourney	Keokuk	IA	Brenda Workman	Erik Wehr	Signed
100	2020-03-24 15:46	Anonymous (not verified)	216.51.130.87	Lake City Electric, LLC	Limited Liability Company	113 E Main Street, Lake City, IA 51449	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-24	Lonnie R. Daisy	lcelectric@iowatelecom.net	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed	(1) The employer does not elect the employers’ liability coverage.	Lonnie R. Daisy	lcelectric@iowatelecom.net	self	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed
101	2020-03-24 15:49	Anonymous (not verified)	161.69.123.10	Blair Lincoln	Proprietorship	32586 390th St Colesburg, IA 52035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-24	Blair Alan Lincoln	balincoln@gmail.com	Colesburg	County	Iowa	Brandon Mather	Travis Ries	Signed	(1) The employer does not elect the employers’ liability coverage.	Blair Alan Lincoln	balincoln@gmail.com	Owner	Colesburg	County	IA	Brandon Mather	Travis Ries	Signed
102	2020-03-25 11:23	Anonymous (not verified)	206.72.14.249	Brandi Wehr	Proprietorship	123 E Marion St, Sigourney, IA 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-25	Brandi Jo Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	Iowa	Amber Kephart	Mary Beth Knipfer	Signed	(1) The employer does not elect the employers’ liability coverage.	Chelsea Voss	chelsea@grimmrealestate.com	Agent	North English	Iowa	Iowa	Amber Kephart	Mary Beth Knipfer	Signed
103	2020-03-25 11:48	Anonymous (not verified)	174.250.52.2	ReFormin' Homes	Proprietorship	7740 NW 16th Street, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-25	Martin Samuel Ledy	reforminhomes@gmail.com	Ankeny	Iowa	United States	Timothy Allen Raynard	Nicholas Paul Curtis	Signed	(1) The employer does not elect the employers’ liability coverage.	Martin Samuel Ledy	reforminhomes@gmail.com	Same Person	Ankeny	Iowa	United States	Timothy Allen Raynard	Nicholas Paul Curtis	Signed
104	2020-03-26 19:00	Anonymous (not verified)	173.189.167.170	MCB CONSTRUCTION INC	Limited Liability Company	3484 VERMONT ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-26	michael wade bethards	mwbethards@yahoo.com	NEW VIRGINIA	IA	IA	noel isaac	alice lohmann	Signed	(1) The employer does not elect the employers’ liability coverage.	mike bethards	mwbethards@yahoo.com	owner	New Virginia	warren	IA	noel isaac	alice lohmann	Signed
105	2020-03-27 12:15	Anonymous (not verified)	174.219.134.4	Elijah Willier	Proprietorship	805 SE 15th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-27	Elijah Willier	e.willier42798@gmail.com	Grimes	Polk	IA	Isaac Willier	Isaiah Willier	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah Willier	e.willier42798@gmail.com	Self/ sole proprietor	Grimes	Polk	IA	Isaac Willier	Isaiah Willier	Signed

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