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:
976	2022-03-15 10:44	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
977	2022-03-15 12:04	Anonymous (not verified)	38.108.136.192	Gunner Fogle	Proprietorship	307 S. Franklin St. Corydon, IA 50060	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	Gunner Lee Fogle	gunnerfogle@hotmail.com	Corydon	Wayne	IA	Jeremy Fogle	Erika Fogle	Signed	(1) The employer does not elect the employers’ liability coverage.	Gunner Fogle	gunnerfogle@hotmail.com	Myself	Corydon	Wayne	IA	Jeremy Fogle	Erika Fogle	Signed
978	2022-03-15 12:42	Anonymous (not verified)	173.24.17.213	Jose Antonio Hernández Tobar	Limited Liability Company	219 Huisman Cir	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	Jose Antonio Hernandez Tobar	josehernanr5@icloud.com	Marshalltown	Marshall	Iowa	Cindy Garcia Hernandez	Jaquelin Garcia Barajas	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Antonio Hernandez Tobar	josehernanr5@icloud.com	Self	Marshalltown	Marshall	Iowa	Cindy Garcia Hernandez	Jaquelin Garcia Barajas	Signed
979	2022-03-15 13:48	Anonymous (not verified)	72.255.78.146	Custom Climates	Partnership	3305 Highway 1 SW Ste 9A 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.	2022-03-15	Allen Nichols	ranichols4@gmail.com	CEDAR RAPIDS	Iowa	IA	Rose Nichols	Rose Nichols	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen Nichols	ranichols4@gmail.com	spouse	CEDAR RAPIDS	Iowa	IA	Rose Nichols	Rose Nichols	Signed
980	2022-03-16 09:38	Anonymous (not verified)	207.199.231.172	Sean Wursta	Proprietorship	401 Strawberry St Eddyville, IA 52553	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-16	Sean Wurstra	5wurstas@gmail.com	Eddyville	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Self	5wurstas@gmail.com	self	Mahaska	Eddyville	Iowa	James Anderson	Ashley Bryan	Signed
981	2022-03-16 13:51	Anonymous (not verified)	192.95.125.117	W.S. Amsden	Proprietorship	405 E 4th Street Vinton IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-16	William Shane Amsden	nmckenna@fsb-vinton.com	Vinton	Benton	Iowa	Nichole M McKenna	Teresa Wehage	Signed	(1) The employer does not elect the employers’ liability coverage.	William Shane Amsden	nmckenna@fsb-vinton.com	Self	Vinton	Benton	Iowa	Nichole M McKenna	Terie Wehage	Signed
982	2022-03-17 09:22	Anonymous (not verified)	65.132.173.234	DAVE GARDNER CONSTRUCTION	Proprietorship	11936 KIMBALL AVE WATERLOO 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.	2022-03-17	DAVE GARDNER	djg201312@gmail.com	Waterloo	Black Hawk	Iowa	Amy Picha	Gary Rankin	Signed	(1) The employer does not elect the employers’ liability coverage.	Dave Gardner	djg201312@gmail.com	self	Waterloo	Black Hawk	IA	Amy Picha	Gary Rankin	Signed
983	2022-03-18 11:02	Anonymous (not verified)	66.180.9.84	Gary Runyon	Proprietorship	101 Harris St Ste 1 Hastings, IA 51540	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-18	Gary Runyon	garyrunyon26@gmail.com	Henderson	Mills	Iowa	Gary Runyon	Cathy Mardesen	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Runyon	garyrunyon26@gmail.com	owner	Henderson	Mills	Iowa	Gary Runyon	Cathy Mardesen	Signed
984	2022-03-18 11:34	Anonymous (not verified)	207.177.116.48	Craig Jacoba Signs	Proprietorship	20404 Walnut Street Yarmouth, IA 52660	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-18	Craig Allan Jacoba	craigjacoba1@hotmail.com	Yarmouth	Des Moines	Iowa	Amy Moyner	Brenda Levitt	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Jacoba	craigjacoba1@gmail.com	subcontractor	Yarmouth	Des Moines	Iowa	Amy Moyner	Brenda Levitt	Signed
985	2022-03-18 11:39	Anonymous (not verified)	207.177.116.48	Craig Jacoba Signs	Proprietorship	20404 Walnut Street Yarmouth, IA 52660	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-18	Craig Allan Jacoba	craigjacoba1@hotmail.com	Yarmouth	Des Moines	Iowa	Amy Moyner	Brenda Levitt	Signed	(1) The employer does not elect the employers’ liability coverage.	Greater Burlington Partnership - Chamber of Commerce	amoyner@greaterburlington.com	subcontractor	Burlington	Des Moines	Iowa	Amy Moyner	Brenda Levitt	Signed
986	2022-03-18 16:46	Anonymous (not verified)	174.213.145.90	Gonzalez Contractors LLC.	Limited Liability Company	150 NE 41st St Unit 109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-18	Elmer Gonzalez	gonzalez922014@icloud.com	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonaalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Elmer Gonzalez	gonzalez922014@icloud.com	Owner	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonzalez	Signed
987	2022-03-20 10:53	Anonymous (not verified)	75.162.173.186	John Greenman Painting	Proprietorship	111 Village Drive West Des Moines Ia,50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-20	john greenman	greenmanj55@gmail.com	west des moines	iowa	iowa	Angela Kay Olsem	Peggy Ann Greenman	Signed	(1) The employer does not elect the employers’ liability coverage.	John William Greenman	greenmanj55@gmail.com	owner	west des moines	iowa	iowa	Angela Kay Olsem	Peggy Ann Greenman	Signed
988	2022-03-21 10:40	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-20	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	N/A	N/a	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto John Henrickson	henricksonroberto10@gmail.com	Owner	Clinton	IA	United States	N/A	N/A	Signed
989	2022-03-21 10:40	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-20	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	N/A	N/a	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto John Henrickson	henricksonroberto10@gmail.com	Owner	Clinton	IA	United States	N/A	N/A	Signed
990	2022-03-21 15:18	Anonymous (not verified)	174.192.80.32	Chris Binns	Proprietorship	1324 Grand Ave Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-21	Christ Binns	christophersbinns@gmail.com	Davenpory	Scott	IA	Adam Coleman	Rose Snyder	Signed	(1) The employer does not elect the employers’ liability coverage.	Chris Binns	christophersbinns@gmail.com	Same	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed
991	2022-03-21 15:25	Anonymous (not verified)	64.191.6.226	Wheeler Painting	Proprietorship	102 Maple Circle Waverly Iowa 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.	2022-03-21	Jon Wheeler	jon.wheeler67@gmail.com	Waverly	Bremer	Iowa	Jason Grant	Richard Grant	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon Wheeler	jon.wheeler67@gmail.com	Owner	Waverly	Bremer	Iowa	Jason Grant	Richard Grant	Signed
992	2022-03-21 19:42	Anonymous (not verified)	174.192.66.11	Christopher Binns	Proprietorship	1324 Grand Ave, Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-21	Christopher Binns	christophersbinns@gmail.com	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Binns	christophersbinns@gmail.com	same	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed
993	2022-03-22 10:36	Anonymous (not verified)	173.18.6.21	Clay Winkelmann	Proprietorship	1652 227th Street, Fontanelle, IA 50846	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-22	Clay Winkelmann	crwwproperties@gmail.com	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernan	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay Winkelmann	crwwproperties@gmail.com	Owner	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernan	Signed
994	2022-03-22 12:19	Anonymous (not verified)	75.162.125.176	performance painting llc	Limited Liability Company	4905 nw 4th 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.	2022-03-22	thomas lilly	TLilly816@aol.com	ankeny	IOWA	United States	Sharon kay Gaulke	Charles Thomas Cater	Signed	(1) The employer does not elect the employers’ liability coverage.	Performance Painting LLC	TLilly816@aol.com	owner	ankeny	IOWA	United States	Sharon Kay Gaulke	Charles Thomas Cater	Signed
996	2022-03-22 23:37	Anonymous (not verified)	173.27.235.109	patriot t services	Proprietorship	205 park st carlisle , ia 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-22	TRAVIS KEENEY	knytrav@aol.com	carlisle	warren	iowa	james Ren	Jesse Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Keeney	knytrav@aol.com	myself	carlisle	warren	iowa	james ren	jesse parker	Signed
997	2022-03-23 06:15	Anonymous (not verified)	167.142.233.235	Betsy Harms Agency LLC	Limited Liability Company	101 Sherman Ave, Ackley, IA 50601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Betsy Harms	bharms@phillipsstafford.com	Ackley	Franklin	IA	Levi Harms	Patricia Harms	Signed	(1) The employer does not elect the employers’ liability coverage.	Betsy Harms	bharms@phillipsstafford.com	Self	Ackley	Franklin	IA	Levi Harms	Patricia Harms	Signed
998	2022-03-23 08:34	Anonymous (not verified)	104.201.100.158	L Peterson Insurance, LLC	Limited Liability Company	603 Pleasant View Drive Des Moines, IA 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Lucas Peterson	lpeterson@phillipsstafford.com	Des Moines	Polk	Iowa	Luke Van Roekel	Sam Debartolo	Signed	(1) The employer does not elect the employers’ liability coverage.	Lucas Peterson	lpeterson@phillipsstafford.com	Owner	Des Moines	Polk	Iowa	Luke Van Roekel	Sam Debartolo	Signed
999	2022-03-23 08:39	Anonymous (not verified)	104.201.100.158	Van Roekel Insurance	Limited Liability Company	25919 330th Ct, Adel Iowa 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Luke Jon Van Roekel	Lvanroekel@phillipsstafford.com	Adel	Dallas	Iowa	Megan Van Roekel	Luke Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke Jon Van Roekel	lvanroekel@phillipsstafford.com	Owner	Adel	IA	United States	Megan Van Roekel	Luke Peterson	Signed
1000	2022-03-23 10:24	Anonymous (not verified)	75.162.12.87	Eric Louvan	Proprietorship	2840 104th 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.	2022-03-23	Eric Louvan	elouvan@phillipssstafford.com	Ankeny	Polk	Iowa	Brandon Johnson	Ann Louvan	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Phillips	bphillips@phillipsstafford.com	Employee	Urbandale	Polk	IA	Eric Louvan	Luke Vanroekel	Signed
1001	2022-03-23 10:37	Anonymous (not verified)	104.201.100.158	Joel Jacobsen	Proprietorship	1337 S 7th 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.	2022-03-23	Joel Jacobsen	jjacobsen@phillipsstafford.com	Adel	Iowa	United States	Luke Peterson	Luke van Roekel	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Jacobsen	jjacobsen@phillipsstafford.com	Self	Adel	Iowa	United States	Luke Peterson	Luke Van Roekel	Signed
1002	2022-03-23 13:04	Anonymous (not verified)	174.255.6.78	Gonzalez Contractors LLC.	Limited Liability Company	240 NE 41st St unit 203	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Elmer Gonzalez	gonzalez922014@icloud.com	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Elmer Gonzalez	gonzalez922014@icloud.com	Owner	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonzalez	Signed
1003	2022-03-23 13:06	Anonymous (not verified)	24.149.3.190	Thomas Wedmore	Proprietorship	200 State St, Ste 202G, 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.	2022-03-23	Thomas Wedmore	twedmore@phillipsstafford.com	Cedar Falls	IA	United States	Bradley Phillips	Joshua Stafford	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Wedmore	twedmore@phillipsstafford.com	Self	Reinbeck	Grundy	IA	Bradley Phillips	Joshua Stafford	Signed
1004	2022-03-23 15:01	Anonymous (not verified)	104.201.110.2	Ryan Fischer	Proprietorship	809 8th St 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.	2022-03-23	Ryan Fischer	rfischer@phillipsstaffod.com	Des Moines	Polk	IA	Josh Stafford	Desiree Dennis	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Fischer	rfischer@phillipsstafford.com	Self	DES MOINES	IA	United States	Josh Stafford	Desiree Dennis	Signed
1006	2022-03-25 10:26	Anonymous (not verified)	107.115.239.110	Jesus ojeda	Limited Liability Company	866 40th Ave Bettendorf IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-25	Jesus Ojeda	jesusojeda386@gmail.com	2112 20 1/2 Ave Rock Island 61201	United States	Illinois	Cody Dunbar	Tiffani branham	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	cdunbar@leaffilter.com	Install manager	866 40th Ave Bettendorf IA 52722	United States	Iowa	Jordan Nisiewicz	Tiffani Branham	Signed
1007	2022-03-25 10:30	Anonymous (not verified)	208.73.53.194	Cory Lehman	Proprietorship	2428 Keokuk Drive Pella, IA 50219	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-25	Cory Lehman	corysfloors@hotmail.com	Pella	Marion	Iowa	Trisha K Klok	Terri Van Ryswyk	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Lehman	corysfloors@hotmail.com	Self	Pella	Marion	Iowa	Trisha K Klok	Terri Van Ryswyk	Signed
1008	2022-03-25 15:15	Anonymous (not verified)	174.192.130.230	Hill's Rehab &Landscape L.L.C	Limited Liability Company	3717 15th ave Moline Illinois 61365	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-25	Joshua hill	joshuajameshill79@gmail.com	Moline	Rock Island	Illinois	Lindsay erin Hill	NICOLE ann lear	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua james hill	joshuajameshill79@gmail.com	President	Moline	Rock Island	Illinois	Lindsay Erin Hill	NIcole ann lear	Signed
1009	2022-03-28 07:24	Anonymous (not verified)	173.18.6.21	Clay Windelmann	Limited Liability Company	362 Public Square, Greenfield, IA 50849	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	C;ay Winkelman	crwwproperties@gmail.com	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernan	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay Winkelmann	crwwproperties@gmail.com	Owner/Self	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernanq	Signed
1010	2022-03-28 09:20	Anonymous (not verified)	173.21.74.26	Self-employed (Stacy Davids)	Proprietorship	35 Lynx Lane, North Liberty, IA 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	Stacy Ann Davids	stacyanndavids@gmail.com	North Libery	Johsnons	IOWA	Darin Gylten	Zara Wanlass	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Ann Davids	stacyanndavids@gmail.com	self	North Liberty	Johnson	Iowa	Darin Gylten	Zara Wanlass	Signed
1011	2022-03-28 10:25	Anonymous (not verified)	207.199.231.172	Brian Carmer	Proprietorship	133 S Iowa Ave, Ottumwa, IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	Brian Carmer	b_carmer@yahoo.com	Ottumwa	Wapello	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Carmer	B_Carmer@yahoo.com	Self	Ottumwa	Wapello	Iowa	James Anderson	Ashley Bryan	Signed
1012	2022-03-28 14:42	Anonymous (not verified)	97.125.50.9	Charles Grimes	Proprietorship	1041 NW Victoria Ln, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	Charles Grimes	maurcedes98@gmail.com	Waukee	Dallas	Iowa	Dave Tomlin	Lavon Grimes	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Grimes	maurcedes98@gmail.com	self	Waukee	Dallas	IA	Dave Tomlin	Lavon Grimes	Signed
1013	2022-03-28 14:54	Anonymous (not verified)	74.115.101.41	Curt Hudson DBA C & L Trucking	Partnership	44651 120th Ave Laurens, IA 50554	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	Curtis Hudson	clhudson@ncn.net	Laurens	Pocahonta	IA	Dale Eng	Troy Rubel	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis Hudson	clhudson@ncn.net	self	Laurens	Pocahontas	IA	Dale Eng	Troy Rubel	Signed
1658	2023-05-23 09:56	Anonymous (not verified)	94.188.205.168	M&D Webster Construction Inc	Proprietorship	1012 Creek Street Webster City IA 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	David Gomez	office.seamlesspros@icloud.com	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed	(1) The employer does not elect the employers’ liability coverage.	David Gomez	office.seamlesspros@icloud.com	Self	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed
1015	2022-03-29 10:56	Anonymous (not verified)	129.255.1.117	Alli Center	Proprietorship	1150 5th St Suite 270 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.	2022-03-29	Miranda K Maday	miranda.maday@alli-center.com	North Liberty	Johnson	Iowa	Zara Wanlass	Jason Knight	Signed	(1) The employer does not elect the employers’ liability coverage.	Zara Wanlass	zara.wanlass@alli-center.com	Co-Owner and Business Manager	Iowa City	Johnson	IA	Miranda K Maday	Jason Knight	Signed
1016	2022-03-29 14:26	Anonymous (not verified)	104.145.202.155	S.M.Trucking	Proprietorship	3270 Hwy 69	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Steve Miller	S.M.Trucking52@gmail.com	3270 Hwy 69 Forest City	Hancock	Ia	Julie Miller	Amy Picha	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Miller	S.M.Trucking52@gmail.com	Owner	3270 Hwy 69 Forest City	Hancock	Ia	Julie Miller	Amy Picha	Signed
1017	2022-03-29 14:53	Anonymous (not verified)	208.81.192.69	Wapsie Valley Insulation, LLC	Limited Liability Company	1180 110th Street Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Lester Kauffman	bookkeeping@robertseddy.com	Fairbank	Buchanan	Iowa	Sarah Van Buren	Julie Ohl	Signed	(1) The employer does not elect the employers’ liability coverage.	Lester Kauffman	bookeeping@robertseddy.com	Same	Fairbank	Buchanan	Iowa	Sarah Van Buren	Julie Ohl	Signed
1018	2022-03-29 15:00	Anonymous (not verified)	97.125.143.50	Modified Originals of Winterset	Limited Liability Company	128 S 3rd Ave, Winterset, IA 50273	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Daniel Maiers	Modifiedoriginals.winterset@gmail.com	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Maiers	Modifiedoriginals.winterset@gmail.com	Self	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williamson	Signed
1019	2022-03-29 16:42	Anonymous (not verified)	104.201.100.158	Nayeri Group LLC	Limited Liability Company	412 SE 17th Court, Grimes, Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Sima Dehghan Nayeri	nayeri.sima@gmail.com	Grimes	Polk	Iowa	Jacob Willis	Lucas Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Sima Nayeri	nayeri.sima@gmail.com	Self	Grimes	Polk	Iowa	Jacob Willis	Lucas Peterson	Signed
1020	2022-03-29 16:53	Anonymous (not verified)	207.32.60.144	J.A. Dahlhauser, Ltd.	Proprietorship	1741 Hwy. 7	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Jaylin A. Dahlhauser	jaydahlhauser@gmail.com	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaylin A. DAhlhauser	jaydahlhauser@gmail.com	Owner	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed
1021	2022-03-30 11:20	Anonymous (not verified)	173.18.22.217	Arti Concrete	Limited Liability Company	6901 SE 14th St Lot #226 Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-30	Gerson David Artero	arti.concrete31@gmail.com	Des Moines	Polk	IA	Lesa Reeves	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerson David Artero	arti.concrete31@gmail.com	Owner	Des Moines	Polk	IA	Lesa Reeves	Erick Schuldt	Signed
1022	2022-03-30 15:08	Anonymous (not verified)	216.51.227.123	Elite Business Cleaning	Limited Liability Company	1350 Kennel Ct Unit C2 north liberty IA 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-30	rogelio morales ortega	info@elitebusinesscleaning.com	iowa city	johnson	Iowa	alma rosa ortega	john Spencer	Signed	(1) The employer does not elect the employers’ liability coverage.	Elite Business Cleaning	info@elitebusinesscleaning.com	Ownerr	iowa city	johnson	iowa	Alma Rosa Ortega	John Spender	Signed
1023	2022-03-31 10:34	Anonymous (not verified)	173.23.251.188	Thede Home Improvement	Proprietorship	1940 86th St Windsor Heights, IA 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-31	Cameron Thede	camthede22@gmail.com	Windsor Heitghts	Polk	IA	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Cameron Thede	camthede22@gmail.com	owner	Windsor Heights	Polk	IA	Tara Murphy	Mike Ryerson	Signed
1024	2022-04-01 09:25	Anonymous (not verified)	173.23.251.188	Norwalk Exterior Home Improvement	Proprietorship	6391 Grimes St Indianola, IA 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-01	John Lester	norwalkexterior@gmail.com	Indianola	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	John Lester	norwalkexterior@gmail.com	owner	Indianola	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed
1025	2022-04-01 09:32	Anonymous (not verified)	173.23.251.188	Dakota Lester	Proprietorship	2711 Cedar St 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.	2022-04-01	Dakota Lester	dlester18@icloud.com	Norwalk	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dakota Lester	dlester18@icloud.com	owner	Norwalk	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed
1026	2022-04-01 14:53	Anonymous (not verified)	173.31.148.43	ARMANDO RESENDEZ	Proprietorship	202 S 13TH ST APT #8 ESTHERVILLE, IA 51334	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-01	ARMANDO RESENDEZ	joel@walkerinsuranceia.com	Estherville	EMMET	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	ARMANDO RESENDEZ	joel@walkerinsuranceia.com	SELF	Estherville	EMMET	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1027	2022-04-01 16:00	Anonymous (not verified)	75.162.62.199	Modern Carpentry Concepts	Limited Liability Company	2012 Ammann Dr. Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-01	Drew Hoffman	d.s.hoffman14@gmail.com	Adel	Dallas	Iowa	Jessica Hoffman	Warren Holder	Signed	(1) The employer does not elect the employers’ liability coverage.	Drew Hoffman	d.s.hoffman14@gmail.com	Same Person	Adel	Dallas	Iowa	Jessica Hoffman	Warren Holder	Signed
1028	2022-04-02 11:01	Anonymous (not verified)	174.198.64.100	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd. Harlan, Iowa 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-02	Richard Nee	great-dain@hotmail.com	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Nee	great-dain@hotmail.com	Self	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed
1029	2022-04-04 12:46	Anonymous (not verified)	174.215.242.124	Bonnie Seely	Proprietorship	43 rainbow court se Cedar Rapids Iowa 52403	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-04	Bonnie Elizabeth seely	bseely4@gmail.com	Cedar Rapids	Linn	Iowa	Mikaela Seely	Noah seely	Signed	(1) The employer does not elect the employers’ liability coverage.	Bonnie Seely	bseely4@gmail.com	Self	Cedar Rapids	IA	United States	Mikaela Seely	Noah Seely	Signed
1030	2022-04-05 06:27	Anonymous (not verified)	172.58.86.173	MR Roofing LLC	Limited Liability Company	8012 Ashridge Rd. Fort Worth, Tx 76134	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	MR Roofing LLC	mrroofing.pr@gmail.com	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Robledo	mrroofing.pr@gmail.com	Owner	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed
1031	2022-04-05 06:47	Anonymous (not verified)	172.58.83.170	Aaron Soboroff	Limited Liability Company	1617 w George Washington Blvd Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Aaron P Soboroff	Treedr47@gmail.com	Davenport	Scott	Iowa	Amanda Isenberg	Josh Strother	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron P Soboroff	Treedr47@gmail.com	Owner Always Mowing	Davenport	Scott	Iowa	Amanda Isenberg	Josh Strother	Signed
1032	2022-04-05 09:21	Anonymous (not verified)	75.89.4.2	KG land works	Limited Liability Company	812 cr 2401 barnsdall Oklahoma 74002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Wyatt ray slone	wyattslone177@gmail.com	Barnsdalll	Osage	OK	Dalton Gardner	Colton Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Kelley	kglandworks@gmail.com	Day helper	Barnsdalll	Osage	OK	Colton Kelley	Dalton Gardner	Signed
1033	2022-04-05 09:36	Anonymous (not verified)	75.89.4.2	KG Land Works	Limited Liability Company	PO Box 931 Barnsdall, Oklahoma 74002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Jacob Curtis Kelley	jacobkelley730@gmail.com	Barnsdall	Osage	Oklahoma	Josiah Daniel Gott	Ainsley Noelle Cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Gardner	kglandworks@gmail.com	Owner	Barnsdall	Osage	Oklahoma	Josiah Daniel Gott	Wyatt Ray Slone	Signed
1034	2022-04-05 11:43	Anonymous (not verified)	75.162.133.214	Riftworks Wood Manufactory	Proprietorship	3807 Adams Ave, Des moines, Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Bryan Siever	bryan@siever.us	Des Moines	IA	United States	Cakeb Payne	Tyler Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryan siever	bryan@siever.us	Business owner	Des Moines	IA	United States	Caleb Payne	Tyler Anderson	Signed
1035	2022-04-05 12:03	Anonymous (not verified)	199.120.121.97	Bruce Peters Painting	Proprietorship	53568 Rosewood Road, Walnut IA 51577	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Bruce Peters	bpeters1992@yahoo.com	Walnut	Pottawattamie	Iowa	Marie Peters	Angie Gettys	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce Peters	bpeters1992@yahoo.com	self	Walnut	Pottawattamie	Iowa	Marie Peters	Angie Gettys	Signed
1036	2022-04-06 10:22	Anonymous (not verified)	67.212.111.166	Precision Painting	Proprietorship	507 Broad Street, Reinbeck Iowa 50669	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-06	Dan Bowser	dbowser.precision.painting@gmail.com	Reinbeck	IA	United States	Kari Houle	Steve Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	CEDAR FALLS	IA	United States	Kari Houle	Steve Swanson	Signed
1653	2023-05-18 09:45	Anonymous (not verified)	94.188.205.166	Darwin Gonzales Rodriguez	Proprietorship	511 5th Street NE 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.	2022-04-10	Darwin Gonzales Rodriguez	office.seamlesspros@icloud.com	Belmond	Wright	Iowa	Soila Perez	Keith Clabaugh	Signed	(1) The employer does not elect the employers’ liability coverage.	Darwin Gonzales Rodriguez	office.seamlesspros@icloud.com	Self	Belmond	Wright	Iowa	Soila Perez	Keith Clabaugh	Signed
1038	2022-04-11 09:43	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-11	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay County	Missouri	Roberto J Henrickson	Cody Dunbar	Signed
1039	2022-04-11 14:33	Anonymous (not verified)	199.120.121.97	Panama Electric	Proprietorship	106 S Railway Panama IA 51562	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-11	Dan Wingert	danwingert@fmctc.com	Panama	Shelby	IA	Laura Wingert	Sylvan Kenkel	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Wingert	danwingert@fmctc.com	Self	Panama	Shelby	IA	Laura Wingert	Sylvan Kenkel	Signed
1040	2022-04-12 09:36	Anonymous (not verified)	173.31.148.43	PAPA'S SMOKIN MEAT	Proprietorship	1940 147TH ST 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.	2022-04-12	KEITH MORISTON	PAPASSMOKINMEAT@GMAIL.COM	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KEITH MORISTON	PAPASSMOKINMEAT@GMAIL.COM	SELF	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1041	2022-04-12 09:39	Anonymous (not verified)	173.31.148.43	PAPA'S SMOKIN MEAT	Proprietorship	1940 147TH ST 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.	2022-04-12	ROXANNE MORISTON	MORISTON2@YAHOO.COM	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ROXANNE MORISTON	MORISTON2@YAHOO.COM	SELF	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1042	2022-04-12 10:10	Anonymous (not verified)	173.20.170.177	Yaseen Albayati	Proprietorship	615 park st apt 1511	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-12	Yaseen Albayati	yaseenali53@gmail.com	Des Moines	Polk	Iowa	Alexis Bagas	Bob Pankrukhin	Signed	(1) The employer does not elect the employers’ liability coverage.	Yaseen Albayati	yaseenali53@gmail.com	self	Des Moines	polk	Iowa	Alexis Bagas	Bob Pankrukhin	Signed
1043	2022-04-12 18:20	Anonymous (not verified)	66.129.218.53	DON'S LOCK & SAFE LLC	Proprietorship	4223 YVETTE ST SUITE 101, 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.	2022-04-12	BRIAN E LOUGH	LOLOCK@LIVE.COM	NORTH LIBERTY	JOHNSON	IOWA	WILLIAM H CRILE	KELLI L SCOTT	Signed	(1) The employer does not elect the employers’ liability coverage.	BRIAN E LOUGH	LOLOCK@LIVE.COM	OWNER	NORTH LIBERTY	JOHNSON	IA	WILLIAM H CRILE	KELLI L SCOTT	Signed
1044	2022-04-13 09:11	Anonymous (not verified)	166.181.81.114	Paul Wall Assemblies LLC	Limited Liability Company	38165 Belgian rd.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-04-13	Paul Carnicle	paulcarnicle@yahoo.com	Strawberry Point	Iowa	United States	Alexander Gabriel Guthrie	Sebastin Thompsin	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Paul Carnicle	paulcarnicle@yahoo.com	Partner	Strawberry Point	Iowa	United States	Alexander Gabriel Guthrie	Sebastin Thompson	Signed
1045	2022-04-13 09:55	Anonymous (not verified)	192.119.237.126	BARGAIN HOUSE	Proprietorship	11 S FREDERICK AVE, OELWEIN, IA 50662	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-13	RICHARD M. BECKER	SHELBY@CIOIA.COM	HAZLETON	BUCHANAN	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed	(1) The employer does not elect the employers’ liability coverage.	RICHARD M. BECKER	SHELBY@CIOIA.COM	OWNER	OELWEIN	FAYETTE	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed
1046	2022-04-14 08:11	Anonymous (not verified)	104.36.120.68	jet drywall	Limited Liability Company	5611 westminster DR #5 cedarfalls 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.	2022-04-14	murion jones	jetdrywall.construction@gmail.com	cedarfalls	black hawk	iowa	murion parely jones	murion jones	Signed	(1) The employer does not elect the employers’ liability coverage.	murion jones	jetdrywal.construction@gmail.com	owner	cedarfalls	black hawk	iowa	Murion Jones JR	Eric Jones	Signed
1047	2022-04-14 08:11	Anonymous (not verified)	104.36.120.68	jet drywall	Limited Liability Company	5611 westminster DR #5 cedarfalls 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.	2022-04-14	murion jones	jetdrywall.construction@gmail.com	cedarfalls	black hawk	iowa	murion parely jones	murion jones	Signed	(1) The employer does not elect the employers’ liability coverage.	murion jones	jetdrywal.construction@gmail.com	owner	cedarfalls	black hawk	iowa	Murion Jones JR	Eric Jones	Signed
1048	2022-04-14 14:17	Anonymous (not verified)	208.38.229.255	Mean Green Lawn Care	Limited Liability Company	2628 W 59th st Davenport Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Anthony mccash	meangreenlawncare20@gmail.com	Davenport	Scott	Iowa	Clarissa Oliva	Julie Thornman	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony McCash	meangreenlawncare20@gmail.com	Owner	Davenport	Scott	Iowa	Clarissa Oliva	Julie Thornman	Signed
1049	2022-04-14 14:29	Anonymous (not verified)	72.13.27.253	Gudenkauf Underground llc	Limited Liability Company	1840 275th St Manchester Ia., 52057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Terry Gudenkauf	tgudenkauf@yousq.net	Manchester	IA	United States	Lisa Gudenkauf	Tim Gudenkauf	Signed	(1) The employer does not elect the employers’ liability coverage.	Terry Gudenkauf	tgudenkauf@yousq.net	Self	Manchester	IA	United States	Lisa Gudenkauf	Tim Gudenkauf	Signed
1050	2022-04-14 14:55	Anonymous (not verified)	173.18.22.217	L & L Home Solutions	Limited Liability Company	3909 sw 14th st DSM IA 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Abraham LaMark	landlhs@gmail.com	des moines	Polk	IA	Jen Lambert	william schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Abraham LaMark	landlhs@gmail.com	friend	des moines	polk	IA	Jen LAmbert	william schuldt	Signed
1051	2022-04-14 17:56	Anonymous (not verified)	199.59.236.46	Triple M Welding	Proprietorship	407 4th St 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.	2022-04-14	Matthew Gibson	matthew.gibson02003@gmail.com	Independence	Iowa	Iowa	Brandon Keener	Cody Laughlin	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Gibson	matthew.gibson02003@gmail.com	Owner	Independence	Iowa	Iowa	Brandon Keener	Cody Laughlin	Signed
1052	2022-04-14 19:05	Anonymous (not verified)	140.82.187.220	McHaddy Constuction	Proprietorship	423 Railroad 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.	2022-04-14	Mick Haddeman	mick@mchaddyconstruction.com	Hudson	Iowa	United States	Linsey Jo Haddeman	Jordan Renae Haddeman	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Haddeman	mick@mchaddyconstruction.com	self	Hudson	IA	United States	Linsey Jo Haddeman	Jordan Renae Haddeman	Signed
1053	2022-04-14 21:08	Anonymous (not verified)	50.83.192.136	John E Snyder JR	Proprietorship	1677 PACIFIC ST, MURRAY, IA 50174	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	John Snyder JR	jrsweldingia@gmail.com	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	Signed	(1) The employer does not elect the employers’ liability coverage.	John Snyder JR	jrsweldingia@gmail.com	Selg	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	Signed
1076	2022-04-28 13:14	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	James Van Ginkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	self	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1077	2022-04-28 13:16	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Bonnie VanGinkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	owner	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1501	2023-03-07 11:27	Anonymous (not verified)	94.188.205.167	Adriene Dangler	Proprietorship	2400 South Shore Dr Clear Lake, IA 50428	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Adrienne Dangler	darrele@ciains.biz	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed
1054	2022-04-15 15:05	Anonymous (not verified)	173.23.251.188	Integrity Design & Development, LLC	Limited Liability Company	810 NW Logan St 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.	2022-04-15	Jerry Houk	integrity.design.development@gmail.com	Ankeny	Polk	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Integrity Design & Development, LLC	integrity.design.development@gmail.com	owner	Ankeny	Polk	Iowa	Tara Murphy	Mike Ryerson	Signed
1055	2022-04-15 20:06	Anonymous (not verified)	166.181.87.86	Steve MORRISON Trucking	Proprietorship	P.O. Box 66 105 N Elm Danville, IA 52623	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-15	Stephen Dwight Morrison	sdmt13@gmail.com	Danville	Des Mounes	IA	Jamie Brown	William Samples	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Dwight Morrison	sdmt13@gmail.com	Owner	Danville	Des Moines	IA	Jamie Brown	William Samples	Signed
1056	2022-04-18 12:04	Anonymous (not verified)	63.152.56.49	Milo’s Construction	Limited Liability Company	8 Erobi ln 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.	2022-04-18	Adriana Celis	celisary0501@gmail.com	Iowa city	Johnson	Iowa	Arcelia Gómez	Karina Beltrán	Signed	(1) The employer does not elect the employers’ liability coverage.	Milo’s Construction	celisary0501@gmail.com	Owner	Iowa city	Johnson	Iowa	Arcelia Gómez	Karina Beltrán	Signed
1057	2022-04-18 12:53	Anonymous (not verified)	204.16.59.10	Iowa’s Gutter Specialist LLC	Limited Liability Company	1390 Lark Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Dustin Halverson	dh42312695@gmail.com	Hampton	IA	United States	Heather Halverson	Michael Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Halverson	dh42312695@gmail.com	Owner	Hampton	IA	United States	Heather Marie Halverson	Michael Alexander Halverson	Signed
1062	2022-04-20 06:46	Anonymous (not verified)	38.121.112.209	Cabinets and Closets by Design LLC	Limited Liability Company	18409 250th Street, Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Timothy Slobodnik	cabinetsandclosetsbydesign@gmail.com	Council Bluffs	Pottawattamie	IA	Tom Pieper	Jim Sietsema	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Slobodnik	cabinetsandclosetsbydesign@gmail.com	self	Council Bluffs	Pottawattamie	IA	Tom Pieper	Jim Sietsema	Signed
1502	2023-03-07 12:40	Anonymous (not verified)	94.188.205.177	Joseph Martin	Limited Liability Company	P O Box 277 Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Joseph Martin	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Al's Roofing LLC	darrele@ciains.biz	Member	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chrus Fye	Signed
1503	2023-03-07 12:45	Anonymous (not verified)	94.188.205.177	Al's Roofing LLC	Limited Liability Company	P O Box 277 Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	John Martin	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Al's Roofing LLC	darrele@ciains.biz	agent	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed
1656	2023-05-22 11:48	Anonymous (not verified)	94.188.205.169	Cesar Arroyo	Proprietorship	2207 Lisa Drive, Webster City IA 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Cesar Arroyo	office.seamlesspros@icloud.com	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed	(1) The employer does not elect the employers’ liability coverage.	Cesar Arroyo	office.seamlesspros@icloud.com	Self	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed
1058	2022-04-19 13:19	Anonymous (not verified)	50.83.154.192	Property Maintenance Services of Iowa LLC	Limited Liability Company	PO Box 166 Low Moor IA 52757	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	Frederick Stewart	curlyfry42000@yahoo.com	LOW MOOR	IA	United States	Irene R Stewart	Derek S Jensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Frederick Lee Stewart	zombiesby2012@gmail.com	Owner	Clinton	IA	United States	Irene R Stewart	Derek S Jensen	Signed
1059	2022-04-19 15:06	Anonymous (not verified)	64.186.23.83	CORRECTIONVILL GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	NICK HEATH	dogboy3485@yahoo.com	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
1060	2022-04-19 15:08	Anonymous (not verified)	64.186.23.83	CORRECTIONVILLE GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	ADAM KELLY	dslkraz@gmail.com	CORRECTIONVILLE	WOOD	IWOA	CANDACE	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
1061	2022-04-19 19:30	Anonymous (not verified)	172.58.83.52	Rodolfo Perez	Proprietorship	3420 E 12th St Des Moines Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	Rodolfo Perez	Elgordo0738@gmail.com	Des Moines	Polk	Iowa	Henry santos	Larry ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Lantz	Info@lantzelite.com	Self employed no workers	Urbandale	Polk	Iowa	Henry santos	Larry ramos	Signed
1063	2022-04-21 08:23	Anonymous (not verified)	207.155.112.81	Prudenterra, LLC	Limited Liability Company	65584 260th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-04-21	Luke Robert Gran	luke@prudenterra.com	Nevada	Story	Iowa	Michael Joseph Coverdale	Judy Rae Coverdale	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Luke Robert Gran	luke@prudenterra.com	Self	Nevada	Story	Iowa	Michael Joseph Coverdale	Judy Rae Coverdale	Signed
1065	2022-04-21 16:26	Anonymous (not verified)	172.58.84.198	Royal Flooring	Limited Liability Company	11801 Hickman Rd Urbandale Iowa 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-21	Alondra Canedo Orta	alondracanedo34@gmail.com	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	Workorders@shoproyalflooring.com	Employee	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed
1066	2022-04-22 11:17	Anonymous (not verified)	50.83.107.151	Delos Steward	Proprietorship	1310 w Main Street Marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-22	Delos Lyle Steward	LDSPlastering2020@gmail.com	Marshalltown	Marshall	Iowa	Chris Hart	Jody Steward	Signed	(1) The employer does not elect the employers’ liability coverage.	LDS Plastering	ldsplastering2020@gmail.com	Owner	Marshalltown	Marshall	Iowa	Chris Hart	Jody Steward	Signed
1067	2022-04-23 11:17	Anonymous (not verified)	166.181.82.231	Black Squirrel Siding LLC.	Limited Liability Partnership	1512 north 1st ave 203s	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-23	Robby Bartosh	zodzoey19@gmail.com	Cedar Rapids	IA	United States	Phoenix Bartosh	Elijah Irish	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah Petsche	Blacksquirrelsiding@gmail.com	business partner	coralville	johnson	iowa	Phoenix Bartosh	Elijah Irish	Signed
1068	2022-04-25 06:07	Anonymous (not verified)	172.58.84.213	Alondra Canedo Orta	Limited Liability Company	4100 Hubbell Ave Apt#80 Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-25	Alondra Canedo Orta	alondracanedo34@gmail.com	Des Moines	Polk county	Iowa	Marvin Bonilla	Alondra Canedo	Signed	(1) The employer does not elect the employers’ liability coverage.	Alondra Canedo Orta	alondracanedo34@gmail.com	Subcontractor Installer	Des Moines	Polk county	Iowa	Marvin Bonilla	Alondra Canedo	Signed
1069	2022-04-26 08:39	Anonymous (not verified)	174.198.72.171	GR Roofing	Proprietorship	802 E County Line Rd Lot 137, Des Moines, Ia 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Eleazar Guzman-Rios	emmanuelgscop.1425@gmail.com	Des Moines	Polk	Iowa	Manny Socop	Julio Andrew	Signed	(1) The employer does not elect the employers’ liability coverage.	Eleazar Guzman-Rios	emmanuelgscop.1425@gmail.com	Owner	Des Moines	Polk	Iowa	Manny Socop	Julio Andrews	Signed
1070	2022-04-26 09:35	Anonymous (not verified)	174.198.72.171	Boyz Roofing LLC	Limited Liability Company	802 E County Lane Rd Lot 25	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Cupertino Rodriguez Hernandez	christopherrodriguez091889@gmail.com	Des Moines	Polk	Iowa	Yoselin Morales	Manny Sokop	Signed	(1) The employer does not elect the employers’ liability coverage.	Cupertino Rodriguez Hernandez	christopherrodriguez091889@gmail.com	Owner	Des Moines	Polk	Iowa	Yoselin Morales	Manny Sokop	Signed
1071	2022-04-26 15:31	Anonymous (not verified)	63.152.69.47	Black squirrel siding llc	Limited Liability Company	1512 n 1st Ave apt c203s coralville,ia52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Jeremiah Petsche	jpetsche44@gmail.com	Coralville	Johnson	Iowa	Jessica schimf	Karl schimf	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah petsche	jpetsche44@gmail.com	Myself	Coralville	Johnson	Iowa	Jessica schimf	Karl schimf	Signed
1072	2022-04-26 16:17	Anonymous (not verified)	166.182.80.187	N & S Trucking Inc	Limited Liability Company	3061 170Th 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.	2022-04-26	Steven Kirk Van Ommen	Stevevo74@yahoo.com	Riverside	Iowa	United States	Steve Van Ommen	Steve Van Ommen	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Kirk Van Ommen	Stevevo74@yahoo.com	President	Riverside	IA	United States	Steve Van Ommen	Steve Van Ommen	Signed

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