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:
585	2021-07-25 20:07	Anonymous (not verified)	75.162.247.154	CJNR Works, LLC	Limited Liability Company	17003 Bowdin Crest Drive, Cypress, Texas 77433	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-25	Christopher Ridgway	christopherridgway@gmail.com	Cypress	Harris	TX	Sophia Ridgway	Mitchel Monahan	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Ridgway	christopherridgway@gmail.com	Self	Cypress	Harris	TX	Sophia Ridgway	Mitchel Monahan	Signed
358	2021-01-12 11:35	Anonymous (not verified)	173.29.116.114	Des Moines Restorations LLC	Limited Liability Company	1701 Pennsylvania Avenue, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-12	Christopher Rogers	chris@desmoinesrestorations.com	Davenport	Scott	IA	Lea Luquire	Lisa Rubio	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Rogers	chris@desmoinesrestorations.com	Owner / Employer	Davenport	Scott	IA	Lea Luquire	Lisa Rubio	Signed
359	2021-01-12 11:37	Anonymous (not verified)	173.29.116.114	Quad City Restorations	Limited Liability Company	1225 E River Drive, Suite 320, 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.	2021-01-12	Christopher Rogers	chris@quadcityrestorations.com	DAVENPORT	Scott	IA	Lea Luquire	Lisa Rubio	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Rogers	chris@quadcityrestorations.com	Owner / Employer	DAVENPORT	Scott	IA	Lea Luquire	Lisa Rubio	Signed
386	2021-02-08 12:10	Anonymous (not verified)	192.30.185.142	CS Iron Design	Proprietorship	311 Powells Addition, Crescent, IA 51526	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-08	Christopher Stoffel	ctstoffel@gmail.com	Crescent	Pottawattamie	IA	Katie Jenks	Nate Blaeser	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Stoffel	ctstoffel@gmail.com	Owner	Crescent	Pottawattamie	IA	Katie Jenks	Nate Blaeser	Signed
1903	2023-11-13 09:08	Anonymous (not verified)	94.188.207.228	Christopher Stone	Proprietorship	2427 S Taft Ave Apt #8	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Christopher Stone	darrele@ciains.biz	Iowa	Cerro Gordo	IA	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Stone	darrele@ciains.biz	self	Mason City	Cerro Gordo	Iowa	Chris Fye	Darrel Elsbernd	Signed
1670	2023-05-30 17:07	Anonymous (not verified)	94.188.207.226	Davis&Viteri LLC	Limited Liability Company	1125 Florida ave apt 519 Ames Iowa 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	Christopher Viteri	davisviteri17@gmail.com	Johnston	Polk	Iowa	Labron davis	Marshalle Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marshalle coleman	marshalle.coleman@yahoo.con	Friend	Ames	Story	Iowa	Marshalle coleman	Labron davis	Signed
389	2021-02-10 13:59	Anonymous (not verified)	173.24.190.134	Shamrock Lanes, LLC	Limited Liability Company	1304 Broadway, PO Box 304, Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-03	Cindy Flannegan	cindylou1964@hotmail.com	Emmetsburg	Palo Alto	Iowa	Michael Flannegan	Laura Sidles	Signed	(1) The employer does not elect the employers’ liability coverage.	Cindy Flannegan	cindylou1964@hotmail.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Michael Flannegan	Laura Sidles	Signed
1137	2022-06-01 09:05	Anonymous (not verified)	63.170.122.111	sanchez framing construction llc	Limited Liability Company	113 e a st west liberty, ia 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-01	Cindy Sanchez	sanchezframingconst.llc@gmail.com	west liberty	muscatine	iowa	patricia verdines	yajahira estrada	Signed	(1) The employer does not elect the employers’ liability coverage.	n/a	sanchezframingconst.llc@gmail.com	n/a	n/a	n/a	n/a	n/a	n/a	Signed
16	2019-12-31 08:54	Anonymous (not verified)	70.184.208.208	J & D Transportation	Proprietorship	1125 Lew Ross Road Council Bluffs, IA 51501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-31	Clarence Cecil Stogdill	jack@jdmmtrucking.com	Council Bluffs	Iowa	United States	Mickey Jerome Stogdill	Laurie Jo Stogdill	Signed	(1) The employer does not elect the employers’ liability coverage.	Clarence Cecil Stogdill	jack@jdmmtrucking.com	owner-same person	Council Bluffs	Iowa	United States	Mickey Jerome Stogdill	Laurie Jo Stogdill	Signed
473	2021-04-13 11:26	Anonymous (not verified)	65.103.82.36	Quality Renovation	Proprietorship	1406 25th st Moline IL 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-06-21	Clarence Marvin Skipton	marvinthemartien77@gmail.com	Buffalo	Scott	IA	Jennifer Skipton	Rose mary Skipton	Signed	(1) The employer does not elect the employers’ liability coverage.	Clarence Marvin Skipton	marvinthemartien77@gmail.com	Owner	Moline	Rock Island	IL	Jennifer skipton	rose Skipton	Signed
1928	2023-11-29 21:48	Anonymous (not verified)	94.188.205.168	Iowa Evolution Constuction	Partnership	1203 Bluegrass 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.	2022-01-01	Claudia Rodriguez	claudia.rodriguez.213@gmail.com	CEDAR FALLS	IA	United States	Guillermo Nunez	Blanca rodriguez	Signed	(1) The employer does not elect the employers’ liability coverage.	Claudia Rodriguez	claudia.rodriguez.213@gmail.com	Owner	CEDAR FALLS	IA	United States	Guillermo Nunez	Blanca Rodriguez	Signed
1744	2023-07-13 13:52	Anonymous (not verified)	94.188.205.176	T-Rex Construction LLC	Limited Liability Company	1203 Bluegrass Circle Unit 4 Cedar Falls Iowa 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.	2023-07-12	Claudia Rodriguez De Nunez	t.rexbigbiz@gmail.com	CEDAR FALLS	IA	United States	Ana Chavez	Alicia Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Guillermo Nunez	claudia.rodriguez.213@gmail.com	Spouse	CEDAR FALLS	IA	United States	Alicia Garcia	Ana Chavez	Signed
1912	2023-11-16 08:40	Anonymous (not verified)	94.188.205.175	JC LANDSCAPING & LAWN CARE	Proprietorship	4940 E. SHERIDAN AVE 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.	2023-11-16	CLAUDIA TORO PINEDA	CLAUDIAMEP@HOTMAIL.COM	DES MOINES	POLK	IA	BRENDA REEDY	ADAM SMITH	Signed	(1) The employer does not elect the employers’ liability coverage.	CLAUDIA TORO PINEDA	CLAUDIAMEP@HOTMAIL.COM	SELF	DES MOINES	POLK	IA	BRENDA REEDY	ADAM SMITH	Signed
2214	2024-05-08 13:49	Anonymous (not verified)	94.188.205.168	Hagen Installation Solutions LLC	Limited Liability Company	725 Cole 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.	2024-05-08	Clay Allen Hagen	clay.hagenson@gmail.com	Carlisle	Warren	Iowa	Tyler Bumgardner	Spencer Kissinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay Allen Hagen	clay.hagenson@gmail.com	Same person	Carlisle	Warren	Iowa	Tyler Bumgardner	Spencer Kissinger	Signed
1731	2023-07-10 11:12	Anonymous (not verified)	94.188.207.228	Romer & Associates LLC	Limited Liability Company	433 Thomas Avenue, Maquoketa, IA 52060	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Clay K Romer	connellsupply@aol.com	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay K Romer	connellsupply@aol.com	Owner/same	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	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
1379	2022-11-22 11:44	Anonymous (not verified)	166.181.89.236	365 Services LLC	Limited Liability Company	306 hayes st e hazleton iowa 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-22	Clayton marshall davis	Lcrc365@outlook.com	Hazleton	Bucanan	Iowa	Grace lilibridge	Kurt king	Signed	(1) The employer does not elect the employers’ liability coverage.	Clayton marshall davis	Lcrc365@outlook.com	Owner	Hazleton	Bucanan	Iowa	Kurt kind	Grace lilibridge	Signed
905	2022-02-08 10:23	Anonymous (not verified)	74.115.101.41	Triple TTT Transport, LLC	Limited Liability Company	307 7th Avenue SE, Belmond, IA 50541	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-08	Clint C Christians	christiansclint0@gmail.com	Pocahontas	pocahontas	Iowa	Dale R Eng	Cheri Zimmerman	Signed	(1) The employer does not elect the employers’ liability coverage.	Clint Christians	christiansclint0@gmail.com	Partner	Pocahontas	Pocahontas	Iowa	Dale Eng	Cheri Zimmerman	Signed
639	2021-09-13 16:10	Anonymous (not verified)	50.81.97.207	Copic Home Maintenance LLC dba Des Moines Drywall Repair	Limited Liability Company	1548 24th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-13	Clint R Copic	crcopic@gmail.com	Des Moines	Polk	Iowa	Veronica G. Torres	Dan Waidelich	Signed	(1) The employer does not elect the employers’ liability coverage.	Clint R Copic	dmdrywallrepair@gmail.com	self	Des Moines	Polk	Iowa	Veronica G Torres	Dan Waidelich	Signed
83	2020-02-28 12:55	Anonymous (not verified)	204.16.58.27	Baltes Trucking LLC	Limited Liability Company	203 N Gilmore Ave New Hampton IA 50659	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-28	Clinton Lee Baltes	clintbaltes@gmail.com	New Hampton	Chickasaw	Iowa	Tammy Robinson	Richard Kramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Clinton Lee Baltes	clintbaltes@outlook.com	Owner	New Hampton	Chickasaw	Iowa	Tammy Robinson	Richard Kramer	Signed
226	2020-08-07 11:37	Anonymous (not verified)	71.39.227.238	Clinton Luellen	Proprietorship	18591 N Ave, Minburn, IA 50167	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-07	Clinton Luellen	CALuellen@gmail.com	Minburn	Dallas	Iowa	Winette Luellen	Don Richardson	Signed	(1) The employer does not elect the employers’ liability coverage.	Clinton Luellen	CALuellen@gmail.com	Self	Minburn	Dallas	Iowa	Winette Luellen	Don Richardson	Signed
2203	2024-05-06 12:44	Anonymous (not verified)	94.188.207.228	Cma landimprovments	Limited Liability Company	530 50th pleasantville	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-06	Cody authier	cauthier85@gmail.com	Pleasantville	Marion	Iowa	Melissa authier	Valerie vanhelten	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody authier	cauthier85@gmail.com	Self	Pleasantville	Marion	Iowa	Melissa authier	Valerie vanhelten	Signed
553	2021-07-01 08:17	Anonymous (not verified)	66.188.136.150	Cody Belleville	Proprietorship	57167 Copperdate Dr. Elkhart, IN 46516	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-30	Cody Belleville	kschumacher@tricorinsurance.com	Elkhart	Elkhart	IN	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Belleville	kschumacher@tricorinsurance.com	Same	Elkhart	Elkhart	IN	Mitch Kemp	Shuree Behr	Signed
329	2020-12-01 10:02	Anonymous (not verified)	74.84.125.43	BRAINARD ROOFING & CONSTRUCTION COMPANY	Limited Liability Company	4 South Ross St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-01	Cody Brainard	brainardrcc2020@gmail.com	Farmersburg	Clayton	United States	Dave Moellers	Jordan Cannon	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Brainard	brainardrcc2020@gmail.com	I am the authorized agent & employer	Farmersburg	IA	United States	Dave Moellers	Jordan Cannon	Signed
1146	2022-06-07 11:51	Anonymous (not verified)	173.27.226.177	Evans Endeavors LLC	Limited Liability Company	513 N Roche 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.	2022-06-07	Cody Evans	evansendeavor@gmail.com	Knoxville	Marion	Iowa	Erin Six	Carl stoffer	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Evans	evansendeavor@gmail.com	Myself	Knoxville	Marion	Iowa	Erin six	Carl Stoffer	Signed
49	2020-01-31 12:53	Anonymous (not verified)	74.84.121.206	Cody Kleppe	Proprietorship	1891 337th St Decorah IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Cody Kleppe	darrele@ciains.biz	Decorah	Winneshiek	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Decorah	Winneshiek	Iowa	Chris Fye	Darrel Elsbernd	Signed
455	2021-03-31 13:35	Anonymous (not verified)	66.188.136.150	Cody Pazicni	Proprietorship	222 Lake Shore Dr. Simpsonville, KY 40067	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-29	Cody Pazicni	kschumacher@tricorinsurance.com	Simpsonville	Shelby	KY	Russell Masartis	Jordan Pape	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Pazicni	kschumacher@tricorinsurance.com	Same	Simpsonville	Shelby	KY	Russell Masartis	Jodan Pape	Signed
700	2021-10-29 11:04	Anonymous (not verified)	174.198.66.50	T&C Lawn Care LLC	Limited Liability Partnership	1827 Black Hawk St Waterloo IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Cody R Woodley	cody.woodley50@gmail.com	Cedar Falls	Blackhawk	Iowa	Tara R Woodley	Sara Woodley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristi S. Demuth Agency, Inc.	kdemuth@amfam.com	Client	Waverly	Bremer	Iowa	Cody R Woodley	Tyler M Croft	Signed
901	2022-02-06 16:48	Anonymous (not verified)	50.83.154.236	Cole Jurgle	Proprietorship	409 West riverside drive prophetstown IL 61277	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-05	Cole Alexander Jurgle	cole.jurgle@gmail.com	Prophetstown	Whiteside	Illinois	Nicholas Ray Jurgle	Misty Ann Jurgle	Signed	(1) The employer does not elect the employers’ liability coverage.	Cole Alexander Jurgle	cole.jurgle@gmail.com	self	Prophetstown	Whiteside	Illinois	Nicholas Ray Jurgle	Misty Ann Jurgle	Signed
259	2020-09-16 15:44	Anonymous (not verified)	174.243.82.6	Freedom Maintenance Services LLC	Limited Liability Company	1633 2nd St Boone, IA 50036	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-16	Cole Keith McDonald	cole.freedomservices@outlook.com	Boone	Boone	IA	Troy Thomas Graen	Kurtis Joseph Wendl	Signed	(1) The employer does not elect the employers’ liability coverage.	Cole Keith McDonald	cole.freedomservices@outlook.com	Me	Boone	Boone	IA	Troy Thomas Graen	Kurtis Joseph Wendl	Signed
969	2022-03-11 16:32	Anonymous (not verified)	74.115.101.41	Slaikeu Transport LLC	Limited Liability Company	2459 Pine Ave, Humboldt, IA 50548	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-11	Cole Slaikeu	cole.slaikeu@gmail.com	Humboldt	Humboldt	IA	Dale Eng	Troy Rubel	Signed	(1) The employer does not elect the employers’ liability coverage.	Cole Slaikeu	cole.slaikeu@gmail.com	self	Humboldt	Humboldt	IA	Dale Eng	Troy Rubel	Signed
1831	2023-09-08 11:50	Anonymous (not verified)	94.188.207.223	GFORCE	Limited Liability Company	529 Anderson Street Jewell IA 50130	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-06	Colten Abram Griffin	G6@q.com	Ames	Story	Iowa	Scott Andrew Griffin	Hunter Austin Griffin	Signed	(1) The employer does not elect the employers’ liability coverage.	Hunter Austin Griffin	G6@q.com	Partner	Urbandale	Polk	Iowa	Scott Andrew Griffin	Colten Abram Griffin	Signed
1467	2023-02-17 16:14	Anonymous (not verified)	94.188.205.169	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	H & C Construction	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed
1508	2023-03-09 10:34	Anonymous (not verified)	94.188.205.176	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Charles Clarke	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed
964	2022-03-10 12:41	Anonymous (not verified)	107.115.239.27	KG Land Works LLC	Limited Liability Company	P.O. Box 931 Barnsdall Ok 74002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-10	Colton Kelley	kglandworks@gmail.com	Barnsdall	Osage	Oklahoma	Colton Kelley	Dalton Gardner	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Kelley	kglandworks@gmail.com	Owner	Barnsdall	Osage	Oklahoma	Colton Kelley	Dalton Gardner	Signed
1879	2023-10-26 13:17	Anonymous (not verified)	94.188.207.224	CR Exteriors	Proprietorship	1636 Parktown Ct NE Unit 9	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-26	corey becker	cab222.ab@gmail.com	cedar rapids	linn	iowa	Brian Ashlock	Brian Coover	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Becker	cab222.ab@gmail.com	same	Cedar Rapids	Linn	Iowa	Brian Ashlock	Brian Coover	Signed
711	2021-11-04 13:07	Anonymous (not verified)	174.216.69.18	Corey Gramowski	Proprietorship	2101 21st ST Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-04	Corey Gramowski	gramowski@windstream.net	Emmetsburg	Palo Alto	IA	Frank Kliegl	John Heddinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Gramowski	gramowski@windstream.net	Self	Emmetsburg	Palo Alto	IA	Frank Kliegl	John Heddinger	Signed
1359	2022-11-04 10:48	Anonymous (not verified)	173.18.22.217	Lewis Enterprises	Limited Liability Company	2723 Witmer Street Des Moines Ia 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-04	Corey Lewis	coreyboy1990@gmail.com	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Lewis	coreyboy1990@gmail.com	Owner	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed
399	2021-02-15 14:44	Anonymous (not verified)	192.30.185.142	Poss Concrete	Proprietorship	3106 Dodge Ave, Sioux City, IA 51106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-15	Corey Poss	coreyposs1@gmail.com	Sioux City	Woodbury	IA	Katie Jenks	Nate Blaeser	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Poss	coreyposs1@gmail.com	Owner	Sioux City	Woodbury	IA	Katie Jenks	Nate Blaeser	Signed
870	2022-01-28 15:51	Anonymous (not verified)	63.229.189.35	Cory Anderson	Proprietorship	2234 141st St, Fort Dodge, IA 50501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-28	Cory Anderson	coryleeanderson@yahoo.com	Fort Dodge	Webster	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Anderson	abigail@rickmilesartisans.com	Self	Fort Dodge	Webster	Iowa	Abigail Miles	Alex Miles	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
1490	2023-03-03 10:31	Anonymous (not verified)	94.188.205.175	Bagby Lawncar and More	Limited Liability Company	921 Pleasant Street, Des Moines IA 50309	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-03	Cory Michael Bagby	bagbylawncareandmore@gmail.com	921 Pleasant Street	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Bagby	babylawncareandmore@gmail.com	Owner	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed
1627	2023-05-08 13:43	Anonymous (not verified)	94.188.205.169	CR TOTAL PLUMBING, INC.	Limited Liability Company	8190 Southern Hills Circle, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-05	Cory Ranson	crpipes2@yahoo.com	Dubuque	Dubuque	Iowa	Randi Taylor	Michelle Woodman	Signed	(1) The employer does not elect the employers’ liability coverage.	CR Total Plumbing, Inc	crpipes2@yahoo.com	Owner	Dubuque	Dubuque	Iowa	Randi Taylor	Michelle Woodman	Signed
1201	2022-07-11 20:19	Anonymous (not verified)	108.59.100.21	Craig A Selberg dba Selberg Construction	Proprietorship	853 North Fork Hollow Rd, Waukon IA 52172	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-11	Craig A Selberg	selberg.construction65@gmail.com	Waukon	Allamakee	Iowa	Jane M Regan	Nancy K Bechtel	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig A Selberg	selberg.construction65@gmail.com	Employer/Owner	Waukon	Allamakee	Iowa	Jane M Regan	Nancy K Bechtel	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
1851	2023-09-22 12:36	Anonymous (not verified)	94.188.207.229	MNM Construction	Proprietorship	3224 sw 12th place des moines iowa 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.	2023-09-22	craig allen mccormick	craigmccormick.6363@gmail.com	Des Moines	Iowa	Iowa	Tara Murphy	Kristie Hubbard	Signed	(1) The employer does not elect the employers’ liability coverage.	craig mccormick	craigmccormick.6363@gmail.com	self	Des Moines	Iowa	Iowa	Tara Murphy	Kristie Hubbard	Signed
485	2021-04-16 11:58	Anonymous (not verified)	69.57.23.123	CRAIG AUKES	Proprietorship	43397 50TH AVENUE, BUFFALO CENTER, IA 50424	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-16	CRAIG AUKES	cdaukes@yahoo.com	Buffalo Center	Winnebago	Iowa	Steven Heyer	Cindy Mawdsley	Signed	(1) The employer does not elect the employers’ liability coverage.	CRAIG AUKES	cdaukes@yahoo.com	Employer-Proprietor	Buffalo Center	Winnebago	IA	Steven Heyer	Cindy Mawdsley	Signed
1229	2022-07-26 15:56	Anonymous (not verified)	173.31.102.238	Rai Neu Jo LLC	Limited Liability Company	957 Westwood Dr NW Cedar Rapids, Iowa 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-26	Craig Edward Johnson	cejohnson119@yahoo.com	Cedar Rapids	Linn	Iowa	Becky Lynn Johnson	Patricia Ann Coghlan	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Edward Johnson	cejohnson119@yahoo.com	Same person	Cedar Rapids	Linn	Iowa	Becky Lynn Johnson	Patricia Ann Coghlan	Signed
1572	2023-04-13 11:12	Anonymous (not verified)	94.188.205.167	CK Trucking	Proprietorship	24497 Hayes Street, Pleasantville, Iowa 50225	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-13	Craig Kooyman	dmsstumpguy@yahoo.com	Pleasantville	IA	IA	Chad Randleman	James Jordan	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Kooyman	dmsstumpguy@yahoo.com	Owner	Pleasantville	Warren	IA	Chad Randleman	James Jordan	Signed
1877	2023-10-23 15:49	Anonymous (not verified)	94.188.207.228	Craig Michael Wilson	Proprietorship	24538 118th Street, Columbus Junction, IA 52738	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-16	Craig Michael Wilson	tripod109@hotmail.com	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Michael Wilson	tripod109@hotmail.com	Self	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed
1391	2022-12-12 11:13	Anonymous (not verified)	136.35.255.41	Snyder Roofing	Proprietorship	2343 ridge trail ne cedar rapids ia 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-12-12	Craig Snyder	snyderroofingcr@gmail.com	Cedar Rapids	Linn county	Iowa	Jordan Loyd	Charles Wood	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan Loyd	Signed
1218	2022-07-21 10:55	Anonymous (not verified)	173.27.17.3	LeafFilter North LLC	Proprietorship	Bettendorf	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-21	Craig Stang	stangcraig@gmail.com	Silvis	Rock island	IL	Cody Dunbar	Tiffani Branham	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter North LLC	cdunbar@leaffilter.com	Install manager	Bettendorf	Iowa	United States	Cody dunbar	Tiffani Branham	Signed
1227	2022-07-26 09:20	Anonymous (not verified)	173.27.17.3	LeafFilter North LLC	Proprietorship	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.	2022-07-26	Craig Stang	stangcraig@gmail.com	Moline	Rock island	IL	Cody Dunbar	Tiffani Branham	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter North LLC	cdunbar@leaffilter.com	Install manager	Bettendorf	Iowa	United States	Cody dunbar	Tiffani Branham	Signed
1091	2022-05-06 09:54	Anonymous (not verified)	97.127.228.168	American Concrete	Proprietorship	2629 Sheffield dr. Davenport iowa 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-06	Craig wells	craiglwells@hotmail.com	Davenport	Scott	Iowa	Kristin frymoyer	Cameron anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	DK home products	anne@dkhomeproducts.com	Sub contractor	Davenport	Scott	Iowa	Kristin frymoyer	Cameron anderson	Signed
1753	2023-07-18 14:41	Anonymous (not verified)	94.188.205.168	Cruz Lerma	Proprietorship	1439 17th Ct 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.	2023-07-18	Cruz Lerma	deb@picowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Cruz Lerma	deb@piciowa.com	self	Des Moines	Polk	Iowa	Deb Stratton	Kelly K Denger	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
266	2020-09-21 18:08	Anonymous (not verified)	174.126.94.77	Club Fantasy Inc.	Limited Liability Company	P.O. Box 5115 Sioux City Iowa 51102	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-21	Curtis A. Behr	cacbehr@aol.com	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis A. Behr	cacbehr@aol.com	Self	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed
804	2021-12-16 21:51	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson st New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Curtis Allen Masterson	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
2182	2024-04-25 19:37	Anonymous (not verified)	94.188.205.174	Curtis Bunnell sub contractor	Proprietorship	907 s main st sigourney IA 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-23	CURTIS BUNNELL	curt3551.cb@gmail.com	Sigourney	Keokuk	IA	Latisha Bunnell	Wendy Yeo	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis bunnell	curt3551.cb@gmail.com	Same person	Sigourney	Keokuk	IA	Latisha bunnell	Wendy Yeo	Signed
1472	2023-02-20 15:52	Anonymous (not verified)	94.188.207.230	C & A Fox Farms LLC	Limited Liability Company	3275 Valley Ave Orchard IA 50460	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Curtis Fox	sales@foxfarmsllc.com	Orchard	IOWA	United States	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis Fox	sales@foxfarmsllc.com	Self	Orchard	IOWA	United States	Darrel Elsbernd	Chris Fye	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
1683	2023-06-09 07:11	Anonymous (not verified)	94.188.207.226	Daves Boys Moving and Hauling LLC	Limited Liability Company	264 Derbyshire Rd.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-09	Curtis Lane	Curtis@davesboys.com	Waterloo	Blackhawk County	IA	Shelley Caughron	Macray Caughron	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis Lane	Curtis@davesboys.com	Myself	Waterloo	Blackhawk	IA	Shelley Caughron	Macray Caughron	Signed
405	2021-02-17 11:04	Anonymous (not verified)	104.201.67.178	CYE Painting	Limited Liability Company	5202 SE 31st Ct Des Moines,IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-17	CYE Painting	marilopez9657@yahoo.com	Des Moines	Polk	Iowa	Maricela Lopez	Cruz Cabrera	Signed	(1) The employer does not elect the employers’ liability coverage.	Maricela Lopez	marilopez9657@yahoo.com	N/a	Des Moines	Polk	IA	Maricela Lopez	Cruz Cabrera	Signed
1403	2023-01-03 15:23	Anonymous (not verified)	173.20.50.85	Falcon Pride Properties, LLC	Limited Liability Company	1401 State Highway 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-23	D. Jay Ellis	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	D. Jay Ellis	cmins_re@mchsi.com	Owner	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1297	2022-09-07 09:36	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2022-09-07	Dagoberto Nunez	nunezdogoberto730@gmail.com	Iowa City	Johnson	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
1893	2023-11-02 14:39	Anonymous (not verified)	94.188.205.177	Dagoberto Nuñez	Proprietorship	Iowa city	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-02	Dagoberto Nuñez	nunezdagoberto730@gmail.com	833 basswood ln iowa city	Johnson	IA	Darwin salgado	Ramon nuñez	Signed	(1) The employer does not elect the employers’ liability coverage.	Dagoberto Nuñez	nunezdagoberto730@gmail.com	Yo mismo	Iowa city	Johnson	IA	Darwin Salgado	Ramon nuñez	Signed
127	2020-04-24 09:18	Anonymous (not verified)	63.152.82.5	TD Auto Services LLC	Limited Liability Company	451 W Parker St Waterloo IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-27	Dakoda Sellers	dakoda.d.sellers@gmail.com	Waverly	Bremer	IA	Jennie Roster	Dustin Roster	Signed	(1) The employer does not elect the employers’ liability coverage.	Dakoda D Sellers	dakoda.d.sellers@gmail.com	Owner	Waverly	Bremer	IA	Jennie Roster	Dustin Roster	Signed
132	2020-04-27 17:26	Anonymous (not verified)	73.94.97.93	Kota Construction	Limited Liability Company	52 SE Pembrooke Ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-27	Dakota Beaulieu	cody.b@buildwithkota.com	Waukee	IA	United States	Kyli Torkelson	Koray Furrow	Signed	(1) The employer does not elect the employers’ liability coverage.	Dakota Beaulieu	cody.b@buildwithkota.com	Self	Waukee	Dallas	Iowa	Kyli Torkelson	Koray Furrow	Signed
1704	2023-06-23 09:00	Anonymous (not verified)	94.188.205.166	THen & Kramer Construcion, Inc.	Partnership	P.O. Box 283 - Epworth, IA 52045	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Dakota Kramer	dparsons@english-insurance.com	Epworth,	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	dparsons@english-insurance.com	self	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	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
117	2020-04-11 09:08	Anonymous (not verified)	72.255.83.134	MIDWEST AG SOLUTIONS, LLC	Limited Liability Company	4949 PLEASANT ST, STE 204, WEST DES MOINES, IA 50266	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-11	DALE A EASTMAN	dale@emdsm.com	Waukee	Dallas	IA	Gary Marshall	Brittain Bachus	Signed	(1) The employer does not elect the employers’ liability coverage.	DALE A EASTMAN	dale@emdsm.com	same	WAUKEE	DALLAS	IA	GARY MARSHALL	BRITTAIN BACHUS	Signed
382	2021-02-02 13:19	Anonymous (not verified)	192.30.185.142	Double D Weatherization	Proprietorship	2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-02	Dale Gernhart	lakehome@longlines.com	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Gerhart	lakehome@longlines.com	Self	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jennie Ebner	Signed
54	2020-02-06 14:18	Anonymous (not verified)	173.28.28.57	Dale Hansman dba Klinkenborg Hansmann Law Office	Proprietorship	1201 Hwy 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-14	Dale Hansmann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Hansmann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1964	2023-12-22 10:19	Anonymous (not verified)	94.188.207.224	Dale Pahl	Proprietorship	711 N. 1St. B105 Eldridge IA 52748	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-21	Dale Pahl	Pada7910@gmail.com	Eldridge	Scott	Iowa	Samantha weston	Rick mayerhofer	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale	Pada7910@gmail.com	Self	Eldridge	Scott	IA	Samantha weston	Rick Mayerhofer	Signed
915	2022-02-15 16:43	Anonymous (not verified)	199.247.79.215	Dale B Wetherell Trucking	Proprietorship	5844 40th Ave., Alta, IA 51002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-15	Dale Wetherell	barbw@sppinsurance.com	Alta	Iowa	Iowa	Barbara Wetherell	Kelli Turnquist	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Wetherell	barbw@sppinsurance.com	Self	Alta	Buena Vista	IA - Iowa	Barb Wetherell	Kelli Turnquist	Signed
965	2022-03-10 12:44	Anonymous (not verified)	107.115.239.27	KG Land Works LLC	Limited Liability Company	P.O. Box 931	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-10	Dalton Gregory Gardner	kglandworks@gmail.com	Barnsdall	Osage	Oklahoma	Dalton Gardner	Colton Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Gardner	kglandworks@gmail.com	Owner	Barnsdall	Osage	Oklahoma	Dalton Gardner	Colton Kelley	Signed
1963	2023-12-18 14:45	Anonymous (not verified)	94.188.207.227	Elite Excavation Services	Limited Liability Company	13335 Amber Rd X44 Anamosa 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.	2023-12-18	Dalton Starn	eliteexcavationservices97@gmail.com	Anamosa	Jones	Iowa	Chase miller	Nathan Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Starn	eliteexcavationservices97@gmail.com	Owner	Anamosa	Jones	Iowa	Chase miller	Nathan decker	Signed
110	2020-04-06 14:13	Anonymous (not verified)	99.203.98.177	Stifel seasonal services	Limited Liability Company	935 4th street waukee	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-06	Dalton Stifel	daltonstifel@icloud.com	waukee	Dallas	IA	Bryant ternes	Tammy stifel	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Stifel	daltonstifel@icloud.com	Owner	waukee	Dallas	IA	Bryant Ternes	Tammy Stifel	Signed
1726	2023-07-07 18:22	Anonymous (not verified)	94.188.205.168	D&E LLC DBA Kanesville Valley	Limited Liability Company	P.O. Box 337 Council Bluffs, IA, 51502	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Damien Joseph Shull	damienshull@gmail.com	Omaha	Douglas	Nebraska	Angela Shull	John Shull	Signed	(1) The employer does not elect the employers’ liability coverage.	Damien Joseph Shull	damienshull@gmail.com	Self	Omaha	Douglas	Nebraska	Angela Shull	John Shull	Signed
1916	2023-11-21 12:31	Anonymous (not verified)	94.188.205.174	DC Painting	Proprietorship	205 Astor St, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Damion Clement	gcort06@gmail.com	Des Moines	Polk	IA	Brandi Haight	Dennis Clement	Signed	(1) The employer does not elect the employers’ liability coverage.	Damion Clement	gcort06@gmail.com	Owner	205 Astor Street	Polk	IA	Brandi Haight	Dennis Clement	Signed
509	2021-05-10 15:25	Anonymous (not verified)	108.190.5.14	Shift Transport LLC	Limited Liability Company	4215 Kris Line Drive Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-10	Damir Pajazetovic	damirp2015@gmail.com	Waterloo	Black Hawk	Iowa	Fata Pajazetovic	Melda Pajazetovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Adnan Pajazetovic	adoni.shift@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Fata Pajazetovic	Melda Pajazetovic	Signed
360	2021-01-12 12:08	Anonymous (not verified)	75.162.189.102	Super Green Plus Llc	Limited Liability Company	3020 SE 5th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-12	Damon Berry	theatvfan@gmail.com	Des Moines	IA	United States	Naki Brown	Nakima Brown	Signed	(1) The employer does not elect the employers’ liability coverage.	Super Green Plus	theatvfan@gmail.com	owner	Des Moines	IA	United States	Naki Brown	Nakima Brown	Signed
555	2021-07-06 12:06	Anonymous (not verified)	66.188.136.150	Damond Horner	Proprietorship	44 East Grove Monroe, MI 48162	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-02	Damond Horner	kschumacher@tricorinsurance.com	Monroe	Monroe	MI	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Damond Horner	kschumacher@tricorinsurance.com	Same	Monroe	Monroe	MI	Mitch Kemp	Cody McClain	Signed
1175	2022-07-05 07:56	Anonymous (not verified)	64.251.168.116	Daniel Alan Valburg	Proprietorship	27656 SD Hwy 44	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-05	Dan A Valburg	agflyer620@gwtc.net	White River	Mellette	SD	George Ludvic	Julie Ludvik	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Alan Valburg	agflyer620@gwtc.net	proprieter	White River	mellette	SD	George Ludvik	Julie Ludvik	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
23	2020-01-02 14:54	Anonymous (not verified)	173.17.129.166	Dan Gudenkauf	Proprietorship	3277 180th Ave, Ryan, IA 52330	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-02	Dan Gudenkauf	dandselectricmotor@gmail.com	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Gudenkauf	dandselectricmotor@gmail.com	Owner	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed
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
53	2020-02-06 11:09	Anonymous (not verified)	65.100.22.228	Bostian Captioning Service, Inc.	Proprietorship	712 8th Avenue NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-06	Dana Bostian	danabostian@msn.com	Oelwein	IA	United States	Lynne Koch	Billie Winters	Signed	(1) The employer does not elect the employers’ liability coverage.	Dana Bostian	danabostian@msn.com	President of Proprietorship	Oelwein	IA	United States	Lynne Koch	Billie Winters	Signed
490	2021-04-20 14:06	Anonymous (not verified)	173.18.16.129	frey construction	Limited Liability Company	1388 205th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-20	Dana Frey	dingaf37@yahoo.com	Creston	Union	Iowa	Lesa Reeves	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Dana Frey	dingaf37@yahoo.com	owner	Creston	Union	Iowa	Lesa Reeves	Kelly Coluzzi	Signed
1452	2023-02-13 16:49	Anonymous (not verified)	94.188.207.228	The Wine Shop, LLC	Limited Liability Company	305 Main St, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-02-13	Dana Swasand	danaswasand@rocketmail.com	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Dana Swasand	danaswasand@rocketmail.com	Owner/Member	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed
1886	2023-10-31 15:53	Anonymous (not verified)	94.188.205.176	CEM Businesses LLC	Limited Liability Company	608 Evergreen Cir Nw Bondurant, IA 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-31	Dane McDonald	dane.mcdonald@stellar-solar.net	Bondurant	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed	(1) The employer does not elect the employers’ liability coverage.	Dane McDonald	dane.mcdonald@stellar-solar.net	Self	Bondurant	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed
445	2021-03-23 12:34	Anonymous (not verified)	172.58.84.232	XD PAINTING	Limited Liability Company	1233 Herold Ave Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-23	Daniel Alcaraz Suarez	xdpainting@gmail.com	Des Moines	Polk county	Iowa	Anthony Maland	Marcus Ross	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Alcaraz Suarez	xdpainting@gmail.com	None	Des Moines	Polk county	Iowa	Anthony maland	Marcus Ross	Signed
59	2020-02-11 11:34	Anonymous (not verified)	198.167.182.164	Besch Electric LLC	Limited Liability Company	317 Sycamore St, Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-03	Daniel Besch	beschd@hotmail.com	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Besch	beschd@hotmail.com	Managing Member	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed
286	2020-10-21 18:32	Anonymous (not verified)	173.218.73.44	Bilyeu Underground LLC	Limited Liability Company	1136 W. Irene Ct. Nixa, MO 65714	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Daniel Bilyeu	danielbilyeu@gmail.com	Nixa	Christian	Missouri	Gary George Bilyeu	Chad Anthony Charles	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Bilyeu	danielbilyeu@gmail.com	Owner	Nixa	Christian	Missouri	Gary George Bilyeu	Chad Anthony Charles	Signed
1101	2022-05-13 12:55	Anonymous (not verified)	174.199.102.54	Daniel Blanco	Proprietorship	1403 2nd 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.	2022-05-13	Daniel Blanco	chindan77@yahoo.com	Ft Dodge	Webster	IA	Vanessa Blanco	Elva Castañeda	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Ft Dodge	Webster	IA	Vanessa Blanco	Elva Castañeda	Signed
1900	2023-11-09 23:24	Anonymous (not verified)	94.188.207.224	Daniel Blanco	Proprietorship	1403 2nd 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.	2023-11-09	Daniel Blanco	chindan77@yahoo.com	Fort Dodge	IA	United States	Vanessa Blanco	Jorge Blanco	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Fort Dodge	IA	United States	Elva Castañeda	Vanessa Blanco	Signed
1393	2022-12-13 12:45	Anonymous (not verified)	50.82.133.22	Ponderosa Outdoor	Limited Liability Partnership	104 Vista Dr Montezuma, Ia 50171	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-13	Daniel Deaver	ponderosaoutdoor@gmail.com	Altoona	Polk	Iowa	Faith Deaver	Jessi Perkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Deaver	ponderosaoutdoor@gmail.com	self	Altoona	Polk	Iowa	Faith Deaver	Jessi Perkins	Signed
913	2022-02-14 18:50	Anonymous (not verified)	72.25.23.147	Teimer Trucking	Limited Liability Company	3277 102nd St. Durant, IA 52747	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-14	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Cedar	Iowa	Barry Boll	Jennifer Treimer	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Owner	Tipton	Cedar	Iowa	Barry Boll	Jennifer Treimer	Signed
1803	2023-08-15 19:03	Anonymous (not verified)	94.188.207.224	Teimer Trucking LLC	Limited Liability Company	3277 102nd St. Durant, IA 52747-9524	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-15	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Iowa	United States	Spencer Lea Parsons	Sydney Rae Lane	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Self	Tipton	Iowa	United States	Spencer Lea Parsons	Sydney Rae Lane	Signed

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