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:
18	2019-12-31 13:36	Anonymous (not verified)	162.253.44.28	Wade Roth DBA Roth TV and Appliance	Proprietorship	1004 12th St, Belle Plaine, IA 52208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2019-12-09	Wade Roth	WADEROTH@NETINS.NET	Belle PLaine	Benton	Iowa	Robert Sydnes	Robert Sydnes	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Wade Roth	WADEROTH@NETINS.NET	Self	Belle Plaine	Benton	Iowa	Robert Sydnes	Kurt Feller	Signed
1761	2023-07-26 08:40	Anonymous (not verified)	94.188.207.224	Gerk Trucking	Proprietorship	401 W college, Stacyville, IA 50476	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Charles W. Gerk	cwgerk@gmail.com	Stacyville	Mitchell	iowa	Jeannie Lemke	Robin Tabbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles W. Gerk	cwgerk@gmail.com	Same	Stacyville	Mitchell	Iowa	Jeannie Lemke	Robin Tabbert	Signed
130	2020-04-27 10:36	Anonymous (not verified)	66.188.136.150	David Roberts	Proprietorship	2600 Butterfield, PO Box 3251 Dubuque, IA 52004	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-24	David Roberts	buman6578@gmail.com	Dubuque	Dubuque	IA	Russell Masartis	Angie Olds	Signed	(1) The employer does not elect the employers’ liability coverage.	David Roberts	kschumacher@tricorinsurance.com	Owner Operator is Employer	Dubuque	Dubuque	IA	Russell Masartis	Angie Olds	Signed
1792	2023-08-08 20:19	Anonymous (not verified)	94.188.207.229	Faith Based Construction	Limited Liability Company	6820 Holcomb 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.	2023-08-08	Toby Andrew Johns	tobyjohns28@gmail.com	URBANDALE	Polk	United States	Melanie Jo Ayersman	Emma Stover	Signed	(1) The employer does not elect the employers’ liability coverage.	Toby Andrew Johns	tobyjohns28@gmail.com	self	URBANDALE	Polk	United States	Melanie Jo Ayersman	Emma Stover	Signed
242	2020-08-24 09:27	Anonymous (not verified)	159.242.43.24	Bontreger Seamless Gutters	Proprietorship	501 S Center St. Zearing Ia 50278	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-24	Harvey Bontreger	borntrgerharvey@gmail.com	Zearing	Story	Ia	Alex G Meier	Daniel Wunschel	Signed	(1) The employer does not elect the employers’ liability coverage.	Harvey Bontreger	borntrgerharvey@gmail.com	Owner	Zearing	Story	Ia	Alex G Meier	Daniel Wunschel	Signed
1904	2023-11-13 09:27	Anonymous (not verified)	94.188.207.224	Paul White	Proprietorship	4991 Old C Boscobel, WI 53805	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Paul White	darrele@ciains.biz	Boscobel	Grant	Wisconsin	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul White	darrele@ciains.biz	self	Boscobel	Grant	Wisconsin	Chris Fye	Darrel Elsbernd	Signed
354	2021-01-11 15:04	Anonymous (not verified)	71.199.85.251	Heather Hampton Cooper Consulting, llc	Limited Liability Company	412 Mango Cir, Saint Augustine, Florida 32095	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-11	Heather H Cooper	hcooper1@comcast.net	Saint Augustine	Saint Johns	FL	Terry l. Cooper	Lauren Rivera	Signed	(1) The employer does not elect the employers’ liability coverage.	Heather H Cooper	hcooper1@comcast.net	Owner	Saint Augustine	Saint Johns	FL	Terry Cooper	Lauren Rivera	Signed
2016	2024-02-01 09:20	Anonymous (not verified)	94.188.207.225	Imperium Outdoor Solutions	Proprietorship	114 W Clanton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	Austin Beener	abeener033@gmail.com	St Charles	IA	United States	Austin Beener	Austin Beener	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Beener	abeener033@gmail.com	Operator	St Charles	IA	United States	Austin Beener	Austin Beener	Signed
466	2021-04-08 09:58	Anonymous (not verified)	216.81.153.249	Supreme Express Transport LLC	Limited Liability Company	609 Euclid Ave, Cherokee, IA 51012	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-10	Liana Gil	liana2702@gmail.com	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Gill	liana2702@gmail.com	Owner	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	Signed
2128	2024-03-29 09:52	Anonymous (not verified)	94.188.207.228	Mason Quality and Sons LLC	Proprietorship	18921 Willow St Omaha Ne 68136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-29	Joel Castillo	drake.centurion@gmail.com	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Castillo	drake.centurion@gmail.com	self	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed
578	2021-07-16 15:26	Anonymous (not verified)	184.80.177.137	Scotty's Appliance & TV, LLC	Limited Liability Company	529 5th St NW - Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-16	Sandra Krogman	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	jheims@english-insurance.com	agent	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed
690	2021-10-26 14:23	Anonymous (not verified)	65.144.174.26	Santiago Rojas	Proprietorship	1359 22nd st Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Santiago Rojas	rojassr09@gmail.com	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	Signed	(1) The employer does not elect the employers’ liability coverage.	Santiago Rojas	rojassr09@gmail.com	Owner	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	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
802	2021-12-16 21:44	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	Jeffrey Allen Webster	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
1105	2022-05-16 13:40	Anonymous (not verified)	174.235.192.160	Travis Montgomery Trucking LLC	Limited Liability Company	701 N 4th street Plainview Ne 68769	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-16	Travis Montgomery	travismontgomery76@gmail.com	Plainview	Pierce	Nebraska	Tim Woslager	Trent Montgomery	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Montgomery Trucking LLC	travismotgomery76@gmail.com	Owner	Plainview	Pierce	Nebraska	Trent Montgomery	Tim woslager	Signed
1217	2022-07-21 06:51	Anonymous (not verified)	209.152.88.53	Bullard Accounting Services, LLC	Limited Liability Company	4519 Scouts View Dr, Central City, IA 52214	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Michael Bullard	mikeandkarenbullard@gmail.com	CENTRAL CITY	IA	United States	Karen Bullard	Nicole Nassif	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Bullard	mikeandkarenbullard@gmail.com	President of Company	CENTRAL CITY	IA	United States	Karen Bullard	Nicole Nassif	Signed
1329	2022-10-10 10:55	Anonymous (not verified)	173.25.222.69	Eli's	Limited Liability Company	931 S Van Buren St Iowa City, Iowa 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-10	Elijah Ortiz	eortiz15@gmail.com	Iowa City	Johnson	Iowa	Erica Mason	Bryan Horrell	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah Ortiz	eortiz15@gmail.com	Proprietor	Iowa City	Johnson	Iowa	Erica Mason	Bryan Horrell	Signed
1441	2023-02-06 14:37	Anonymous (not verified)	69.40.94.166	ESW CONSTRUCTION INC	Partnership	35 HIGHWAY 22, KESWICK IA 50136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-06	JOSHUA EDMUNDSON	payten@iowacropservice.com	KESWICK	KEOKUK	IOWA	JULIE WHITE	REBECCA APPLEGET	Signed	(1) The employer does not elect the employers’ liability coverage.	BARBARA EDMUNDSON	barb@iowacropservice.com	agent	SIGOURNEY	KEOKUK	IOWA	JULIE WHITE	REBECCA APPLEGET	Signed
1553	2023-04-04 14:52	Anonymous (not verified)	94.188.205.177	TOPSOIL OUTDOOR SERVICES	Limited Liability Company	4919 SCHUBERT 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.	2023-04-04	LIBAN	topsoiloutdoor@gmail.com	AMES	IA	United States	Liban Wetzberger	Liban Wertzberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Liban Wertzberger	topsoiloutdoor@gmail.com	Owner	AMES	IA	United States	Liban Wertzberger	Liban Wertzberger	Signed
1665	2023-05-27 17:41	Anonymous (not verified)	94.188.205.175	Diamond Spray Foam and Coatings LLC	Limited Liability Company	19024 345th St, Forest City, IA 50436	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-27	Joshua Gregory Diamond	dsfinsulation@gmail.com	Forest City	Winnebago	IA	Brett Busenitz	Bret Guggisburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Gregory Diamond	dsfinsulation@gmail.com	Owner	Forest City	Winnebago	IA	Brett Busenitz	Bret Guggisburg	Signed
34	2020-01-10 15:56	Anonymous (not verified)	74.84.121.206	Milferd Loewen	Proprietorship	6568 Hwy 63, Lime Springs, IA 52155	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-10	Milferd Loewen	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel J. Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Milferd Loewen	darrele@ciains.biz	self	Lime Springs	Howard	Iowa	Darrel J. Elsbernd	Chris Fye	Signed
146	2020-05-01 05:34	Anonymous (not verified)	174.217.5.175	Five Nail Services	Limited Liability Company	32379 162nd Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-01	Ralph Chiodo	rchiodo2@gmail.com	Woodward	IA	United States	Ralph Chiodo	Rebecca Chiodo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ralph Chiodo	rchiodo2@gmail.com	Self	Woodward	IA	United States	Ralph Chiodo	Rebecca Chiodo	Signed
1808	2023-08-17 17:17	Anonymous (not verified)	94.188.205.168	Treimer 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.	2023-08-17	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Iowa	United States	Sydney Rae Lane	Spencer Lea Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Self	Tipton	Iowa	United States	Syndey Rae Lane	Spencer Lea Parsons	Signed
258	2020-09-15 13:14	Anonymous (not verified)	50.83.182.140	Moyer Painting	Proprietorship	934 Norwood Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	jerome Moyer	moyer_painting@live.com	Norwalk	IA	United States	Sally Moyer	Adam Adams	Signed	(1) The employer does not elect the employers’ liability coverage.	jerome b moyer	moyer_painting@live.com	Self	norwalk	IA	United States	sally moyer	Adam Adams	Signed
1920	2023-11-22 08:40	Anonymous (not verified)	94.188.205.166	Demolition Services of Iowa, llc	Limited Liability Company	221 North Grant Ave., Elkhart, IA 50073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-22	William Albert Halterman	DemolitionServicesIA@gmail.com	ELKHART	IA	United States	Ashley Whitehill	Zach Whitehill	Signed	(1) The employer does not elect the employers’ liability coverage.	William Albert Halterman	DemolitionServicesIA@gmail.com	self	Elkhart	Polk	IA	Ashley Nicole Lee Whitehill	Zachery Allen Whitehill	Signed
370	2021-01-22 14:23	Anonymous (not verified)	71.39.227.238	Jonathon McClure	Proprietorship	25059 R Ave, Dallas Center, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-22	Jonathon McClure	mcclure.jonathon@gmail.com	Dallas Center	Dallas	Iowa	RoseMary Phillips	Steve Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Jonathon McClure	mcclure.jonathon@gmail.com	Self	Dallas Center	Dallas	Iowa	RoseMary Phillips	Steve Phillips	Signed
2032	2024-02-07 11:05	Anonymous (not verified)	94.188.207.229	NEIL MARTENS	Proprietorship	527 3RD STREET, SOUTH, ALBERT CITY, IA 50510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	NEIL THIESSEN MARTENS	pkmmartens@hotmail.com	ALBERT CITY	BUENA VISTA	IOWA	JOHN CLARENCE OLERICH	ROBERT EUGENE BELT	Signed	(1) The employer does not elect the employers’ liability coverage.	NEIL MARTENS	pkmmartens@hotmail.com	SELF	ALBERT CITY	BUENA VISTA	IOWA	JOHN CLARENCE OLERICH	ROBERT EUGENE BELT	Signed
482	2021-04-14 21:21	Anonymous (not verified)	98.17.35.5	K3 Recycling LLC	Limited Liability Company	14801 180th Ave, Milo, IA 50166	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-14	Charles Raymond Kappelman	charliekappelman@yahoo.com	MILO	Warren	United States	Ryan Matthew Kappelman	John Allen Bahr	Signed	(1) The employer does not elect the employers’ liability coverage.	K3 Recycling LLC	charliekappelman@yahoo.com	Co-owner	Milo	Warren	Iowa	Ryan Matthew Kappelman	John Allen Bahr	Signed
2144	2024-04-10 14:23	Anonymous (not verified)	94.188.205.176	Heaven Sent PC LLC	Limited Liability Company	604 Allamakee St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-10	Justin PIggott	heavensentpetcremation@gmail.com	Waukon	Allamakaee	IA	Jane M Regan	Nancy Bechtel	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Piggott	heavensentpetcremation@gmail.com	LLC Member	Waukon	Allamakee	IA	Jane M Regan	Nancy Bechtel	Signed
594	2021-08-03 13:12	Anonymous (not verified)	166.181.80.73	Leaffilter	Limited Liability Company	866 40th Ave Bettendorf, IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-03	Gerald Landstrum	Teamtony710@gmail.com	103 e Grinnell street Gibson Iowa	Keokuk	Iowa	Jake Nagel	Ty Reindl	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter Gutter Protection	jnagel@leafhome.com	assembler	Bettendorf	Scott	Iowa	Jake nagel	Ty reindl	Signed
897	2022-02-04 15:15	Anonymous (not verified)	163.116.133.119	Schauf Investments LLC	Limited Liability Company	3465 Vermont Street, New Virginia, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-04	Maxwell Schauf	max.schauf@gmail.com	New Virginia	IA	United States	Krisha Schauf	Robin Schauf	Signed	(1) The employer does not elect the employers’ liability coverage.	Maxwell Schauf	max.schauf@gmail.com	General Member	New Virginia	IA	United States	Krisha Schauf	Robin Schauf	Signed
706	2021-11-02 11:45	Anonymous (not verified)	50.82.130.211	Kierstyn Anest	Proprietorship	1200 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-25	Kierstyn Anest	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Kerstyn Anest	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1009	2022-03-28 07:24	Anonymous (not verified)	173.18.6.21	Clay Windelmann	Limited Liability Company	362 Public Square, Greenfield, IA 50849	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	C;ay Winkelman	crwwproperties@gmail.com	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernan	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay Winkelmann	crwwproperties@gmail.com	Owner/Self	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernanq	Signed
818	2022-01-02 11:34	Anonymous (not verified)	184.94.130.66	dylan nelson trucking llc	Limited Liability Company	2011 465th street hanley falls mn 56245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-02	dylan nelson	dylancvi@gmail.com	hanley falls mn	yellow medicine	mn	derek verhelst	mike fales	Signed	(1) The employer does not elect the employers’ liability coverage.	dylan nelson	dylancvi@gmail.com	owner	hanley falls mn	yellow medicine	mn	derek verhelst	mike fales	Signed
1121	2022-05-19 17:45	Anonymous (not verified)	107.115.239.35	KG Land works LLC	Limited Liability Company	P.O. Box 931Barnsdall Oklahoma 74002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-19	Keiven Brooke Slone	keiven.slone@gmail.com	Barnsdalll	Osage	OK	Colton Kelley	Dalton Gardner	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Kelley	kglandworks@gmail.com	Owner	Barnsdalll	Osage	OK	Dalton Garder	Jacob Kelley	Signed
1233	2022-07-28 22:53	Anonymous (not verified)	166.181.84.53	Leaffilter	Limited Liability Company	3060 SE Grimes Blvd Suite 100-300, Grimes, IA 501113060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-28	Mohammed Albayati	mrcarbody.81@gmail.com	Johnston	Polk	Iowa	Tammy Decker	Waffa Albayati	Signed	(1) The employer does not elect the employers’ liability coverage.	Meghan Mcilhon	mmcilhon@leaffilter.com	Human Resources	Grimes	Polk	Iowa	Tammy Decker	Waffa Albayati	Signed
1345	2022-10-25 15:25	Anonymous (not verified)	166.181.82.169	Estling Junk and Garbage Removal	Limited Liability Company	660 West Main Street Apt.5	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2022-10-25	Jacob Steven Estling	JacobEstling1@gmail.com	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jacob Steven Estling	jacobestling1@gmail.com	Owner	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed
1457	2023-02-15 18:06	Anonymous (not verified)	94.188.205.166	Chad Cowan	Limited Liability Company	2108 Locust St West Des Moines IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-15	Chad Stuart Cowan	chad@bigroofing515.com	West Des Moines	Polk	Iowa	Paul Mouw	Rob Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Cowan	rr2cw@yahoo.com	Same	West Des Moines	IA	United States	Paul Mouw	Rob Schultz	Signed
1569	2023-04-12 16:19	Anonymous (not verified)	94.188.205.166	Leaf home solutions llc	Limited Liability Partnership	1595 Georgetown rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-11	Gustavo Lopez	Glopez2616@gmail.com	Des Moines	IA	IA	Ricardo lopez	Maria lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	N/a	sewell@leafhome.com	N/a	Na	Na	Na	Na	Na	Signed
1681	2023-06-08 15:55	Anonymous (not verified)	94.188.207.223	Cross Roads Builders, LLC	Limited Liability Company	3103 21st Street Camanche, IA.52730	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-08	Mark Allan Cross	rcreek2016@gmail.com	Davenport	iowa	United States	Barb Deering	Mike Cross	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Cross	rcreek2016@gmail.com	Owner/President	Davenport	IA	United States	Barb Deering	Mike Cross	Signed
50	2020-02-03 14:55	Anonymous (not verified)	173.28.28.57	Silverleaf Capital, LLC	Limited Liability Company	1606 Palmer Court, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-20	Silverleaf Capital, LLC	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Silverleaf Capital, LLC	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
162	2020-05-19 15:03	Anonymous (not verified)	67.212.114.80	Collum Plumbing, LLC	Limited Liability Company	610 West 20th Street, Cedar Falls, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-19	Stephen Collum	collumplumbing@cfu.net	Cedar Falls	Iowa	United States	Mike Thode	Linda Thode	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Collum	collumplumbing@cfu.net	Member of LLC	Cedar Falls	Black Hawk	Iowa	Mike Thode	Linda Thode	Signed
1824	2023-08-29 16:20	Anonymous (not verified)	94.188.205.176	Miller Construction Siding & Windows, LLC	Limited Liability Company	3104 S.W. 26TH STREET, ANKENY, IA. 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-29	SCOTT MICHAEL DORAU	SMD50021@GMAIL.COM	Ankeny	Polk	United States	Christopher Bohn	Jeffrey Bohn	Signed	(1) The employer does not elect the employers’ liability coverage.	SCOTT MICHAEL DORAU	SMD50021@GMAIL.COM	PRESIDENT	Ankeny	POLK	United States	CHRISTOPHER BOHN	JEFFREY BOHN	Signed
274	2020-10-06 13:18	Anonymous (not verified)	174.250.65.147	Ddp construction	Proprietorship	1923 63rd st. Urbandale , ia 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-06	Dustin a perry	perrythedustin@gmail.com	Urbandale	Polk	Iowa	Luke jackson	Loud jackson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin perry	perrythedustin@gmail.com	Owner	Urbandale	Polk	Iowa	Luke jackson	Loyd jackson	Signed
1936	2023-12-04 10:22	Anonymous (not verified)	94.188.205.174	Turkey River Ag Sales LLC	Limited Liability Company	614 Vernon 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.	2023-12-04	David Ahern	davidahern@turkeyriverag.com	Cresco	IOWA	IOWA	Michelle Ahern	Alyse Ahern	Signed	(1) The employer does not elect the employers’ liability coverage.	Turkey River Ag Sales LLC	davidahern@turkeyriverag.com	Owner	Cresco	Howard	Iowa	Michelle Ahern	Alyse Ahern	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
2048	2024-02-16 07:42	Anonymous (not verified)	94.188.207.224	Alexandra Machedon LLC	Proprietorship	319 N Western Street Stuart, IA 50250	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-16	Alexandra Machedon	ali@alimachedon.com	Stuart	USA	Iowa	Jessica Cash	Vicki Collins	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexandra Machedon	ali@alimachedon.com	Self	Stuart	US	IA	Jessi Cash	Vicki Collins	Signed
498	2021-04-27 12:54	Anonymous (not verified)	173.31.147.225	TYREL KINKADE DBA: KINKADE CONSTRUCTION	Proprietorship	2289 165TH ST UNIT 10D	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-21	TYREL KINKADE	hogtyd97@yahoo.com	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	TYREL KINKADE	JOEL@WALKERINSURANCEIA.COM	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
2160	2024-04-17 18:21	Anonymous (not verified)	94.188.207.226	QC Remodeling LLC	Limited Liability Company	421 West Broadway, Ste 302 Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Fernando Ibarra	ibarra_fernando@hotmail.com	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Ibarra	ibarra_fernando@hotmail.com	Owner	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed
610	2021-08-18 11:15	Anonymous (not verified)	172.58.84.99	LeafFilter North LLC	Partnership	866 40th ave bettendorf iowa 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.	2021-08-18	Thomas R Fuller	tomstl001@yahoo.com	DAVENPORT	Iowa	Iowa	Bob phillips	Julie fuller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Regional field recruiter	Bettendorf iowa	Scott	Iowa	Warren crow	Jordan lloyd	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
722	2021-11-05 14:07	Anonymous (not verified)	209.252.172.87	Jeremiah Lunsford	Proprietorship	624 Carroll Dr SE, Cedar Rapids, IA 52403	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-10	Jeremiah Lundsford	jjaylunsford@gmail.com	Cedar Paids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah Lunsford	jjaylunsford@gmail.com	Self Employed	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	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
834	2022-01-12 17:34	Anonymous (not verified)	67.212.111.166	Cory's Painting LLC	Limited Liability Company	Po Box 1161 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.	2021-01-13	Erik Bjorn Nelson	ebjornnelson@gmail.com	Waterloo	Black Hawk County	Iowa	Kari Houle	Steven John Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk County	Iowa	Kari Houle	Steven John Swanson	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
1470	2023-02-20 08:38	Anonymous (not verified)	94.188.205.167	Level92 Screen Printing LLC	Limited Liability Company	2500 W 2nd Ave Ste 10, Indianola, IA 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Alison Vice	orders@level92.com	Indianola	Warren	Iowa	Bill Bauer	Cindy Bauer	Signed	(1) The employer does not elect the employers’ liability coverage.	Alison Vice	orders@level92.com	Partner	Indianola	Warren	Iowa	Bill Bauer	Cindy Bauer	Signed
1582	2023-04-18 14:04	Anonymous (not verified)	94.188.205.177	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1694	2023-06-16 14:37	Anonymous (not verified)	94.188.205.176	Leaf Home Solutions LLC	Partnership	3060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-16	Caleb Brincks	chbrincks@gmail.com	628 NE 56th St Ankeny IA, 50021	Polk County	Iowa	Melissa Brincks	Anisha Moten	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	AFTON INC	chbrincks@gmail.com	Owner	Ankeny	Polk	Iowa	Melissa Brincks	Anisha Moten	Signed
63	2020-02-17 16:05	Anonymous (not verified)	173.17.12.213	ANA GARCIA GONZALEZ	Limited Liability Company	4023 14TH ST DES MOINES IOWA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-17	Ana Garcia Gonzalez	gjeanettegonzalez@gmail.com	DES MOINES	POLK	IOWA	LUZ SAUCEDA	SANDRA ISABEL SAUCEDA	Signed	(1) The employer does not elect the employers’ liability coverage.	ANA GARCIA GONZALEZ	GJEANETTEGONZALEZ@GMAIL.COM	SELF	DES MOINES	POLK	IA	LUZ SOTELO SAUCEDO	SANDRA ISABEL SAUCEDA	Signed
175	2020-06-05 15:14	Anonymous (not verified)	98.21.202.208	Bloomfield Properties LLC	Limited Liability Company	206 Weaver Road, Bloomfield, IA 52537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-05	Dave Lawrence	terri_roberts58@yahoo.com	Ottumwa	Wapello	Iowa	Sheri Moore	Cassidy Dimmitt	Signed	(1) The employer does not elect the employers’ liability coverage.	Terri Roberts	terri_roberts58@yahoo.com	shareholder	Ottumwa	Wapello	Iowa	Sheri Moore	Cassidy Dimmitt	Signed
1837	2023-09-11 19:10	Anonymous (not verified)	94.188.207.230	TBA Handyman service	Limited Liability Company	619 e 10th st. north newton Iowa 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-11	Joey Conkling	tba050402@gmail.com	newton	jasper	Iowa	Ashton tyler conkling	Bianca Storm Conkling	Signed	(1) The employer does not elect the employers’ liability coverage.	TBA Handyman Service	tbaconstruction02@gmail.com	self	newton	jasper	iowa	Ashton tyler Conkling	Bianca Storm Conkling	Signed
287	2020-10-21 18:35	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	Gary George Bilyeu	garygb1990@gmail.com	Sparta	Christian	Missouri	Daniel Bilyeu	Chad Anthony Charles	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary George Bilyeu	garygb1990@gmail.com	Owner	Sparta	Christian	Missouri	Chad Anthony Charles	Daniel Bilyeu	Signed
1949	2023-12-11 15:20	Anonymous (not verified)	94.188.207.223	Allens construction services llc	Limited Liability Company	509 Nw Scott St Ankeny, Iowa 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-11	Allen Cheville	acsllc515@gmail.com	Ankeny	Polk	IOWA	Allen Cheville	Alexis Zimmerman	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen Cheville	acsllc515@gmail.com	Self	Ankeny	Polk	IOWA	Allen Cheville	Alexis Zimmerman	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
2061	2024-02-28 14:16	Anonymous (not verified)	94.188.205.166	Cael Gulrud	Proprietorship	206 W Main St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-28	Cael Gulrud	gulrud8728@gmail.com	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed	(1) The employer does not elect the employers’ liability coverage.	Cael Gulrud	gulrud8728@gmail.com	Me	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed
511	2021-05-10 17:53	Anonymous (not verified)	173.24.231.27	QSC Snow Removal	Proprietorship	1211 Carroll Boone IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-10	Vincent A Kaylor	phenox32@gmail.com	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Vincent A Kaylor	phenox32@gmail.com	self	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed
2173	2024-04-23 14:19	Anonymous (not verified)	94.188.205.166	Duer and Sons Remodeling, Inc	Partnership	1795 Se 82nd St, Runnells Iowa 50237	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	John Duer	John@duerandsonsremodeling.com	Runnells	Polk	Iowa	Travis Justice	Jake VanGorp	Signed	(1) The employer does not elect the employers’ liability coverage.	John Duer	John@duerandsonsremodeling.com	Owner	Runnells	Polk	Iowa	Travis Justice	Jake VanGorp	Signed
623	2021-08-30 15:03	Anonymous (not verified)	174.198.77.231	Joe Dawson	Proprietorship	1088, Dogwood Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Joe R Dawson	joerdawson@gmail.com	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Joe R Dawson	joerdawson@gmail.com	Owner	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed
926	2022-02-17 15:20	Anonymous (not verified)	166.181.83.68	Staley Trucking LLC	Limited Liability Company	1388 140th 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.	2022-02-17	Travis Staley	staleyracing121@gmail.com	Hampton	Franklin	IA	Tyler Staley	Jeff Staley	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Staley	staleyracing121@gmail.com	President	Hampton	Franklin	IA	Tyler Staley	Jeff Staley	Signed
735	2021-11-11 14:10	Anonymous (not verified)	72.13.16.172	T MILLER TRUCKING LLC	Limited Liability Company	1682 MONROE DRIVE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-18	T MILLER TRUCKING LLC	DAVE@ALLSEASONSTRUCKING.COM	WATERVILLE	ALLAMAKEE	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	T MILLER TRUCKING LLC	dave@allseasonstrucking.com	PRESIDENT	WATERVILLE	ALLAMAKEE	IA	Dave Neuwohner	BEN MOYER	Signed
1038	2022-04-11 09:43	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-11	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay County	Missouri	Roberto J Henrickson	Cody Dunbar	Signed
847	2022-01-20 13:54	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Jesse Nitcher	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Nitcher	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1150	2022-06-10 16:14	Anonymous (not verified)	173.29.125.38	Vernon Tim McClain	Limited Liability Company	2717 Thompson ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-10	Vernon Tim McClain	mcclainlawn@gmail.com	Des Moines	POlk	Iowa	Ilisha Carter	Earl Warren Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	vernon mcclain	mcclainlawn@gmail.com	business owner	des moines	polk	iowa	Ilisha Carter	Earl Warren Jr.	Signed
1262	2022-08-16 12:52	Anonymous (not verified)	74.137.151.70	Golds Custom Grading LLC	Limited Liability Company	Po Box 114 Spencer, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-16	Brad Carlson	brad_carlson@gmail.com	Spencer	Clay	Iowa	Thomas Dunn	Nancy Cassa	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Thomas Dunn	TDUNN@THOMASBRADLEYINSURANCE.COM	Agent	Madison	Dane	Wisconsin	Nancy Cassa	Brad Carlson	Signed
1374	2022-11-17 14:33	Anonymous (not verified)	72.106.129.202	Cowman Consulting and Construction LLC	Limited Liability Company	740 NE Horizon Dr, Waukee IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-17	Khalid Cowman	khalidcowman1@gmail.com	Waukee	Dalls	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Khalid Cowman	khalidcowman1@gmail.com	Self/Owner	Waukee	Dallas	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1486	2023-02-26 17:53	Anonymous (not verified)	94.188.205.177	TURNER LAWN CARE	Limited Liability Company	16493 185th Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-27	JEFF TURNER	jscturner2626@gmail.com	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed	(1) The employer does not elect the employers’ liability coverage.	SHARON RENEE TURNER	jscturner2626@gmail.com	wife	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed
1598	2023-04-25 07:02	Anonymous (not verified)	94.188.205.174	Johnny Pommer	Limited Liability Company	4125, E 30th 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.	2023-04-25	Johnny Pommer	bravojohnny@me.com	Des Moines	United states	IA	Johnny Pommer	Kimberly pommer	Signed	(1) The employer does not elect the employers’ liability coverage.	Johnny Pommer	bravojohnny@me.com	Owner	Des Moines	United States	IA	Johnny Pommer	Kimberly pommer	Signed
1710	2023-06-26 16:10	Anonymous (not verified)	94.188.207.226	Adaptability Plus	Limited Liability Company	904 W 4th St. Waterloo, Iowa 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.	2023-06-26	Timothy Combs	timcombs@afiliowa.org	Waterloo	Iowa	United States	Teresa Tjaden	Mark Moser	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Moser	mpmmoser@gmail.com	PARTNER	WATERLOO	Black Hawk	Iowa	TERSEA TJADEN	TIM COMBS	Signed
79	2020-02-25 17:28	Anonymous (not verified)	66.43.239.175	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-25	Tamara Glendenning	lanceandabby@wccta.net	Davis Junction	Ogle	Il	Dena M. Anderson	Shelly Brus	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Glendenning	lanceandabby@wccta.net	President	Churdan	Greene	IA	Dena M Anderson	Shelly Brus	Signed
191	2020-06-23 16:09	Anonymous (not verified)	173.18.3.76	Look At You LLC	Limited Liability Company	5545 Mills Civic Pkwy Ste 100 West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-23	Amber Keppler	keppler_ark@outlook.com	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed	(1) The employer does not elect the employers’ liability coverage.	Amber Keppler	keppler_ark@outlook.com	LLC Member	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed
1853	2023-09-26 10:16	Anonymous (not verified)	94.188.205.177	Saketh Mahavadi	Limited Liability Company	294 s 83rd street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-26	Saisaketh	sakethmahavadi@gmail.com	West Des Moines	IA	United States	David Chan	Ahnaf Yeasin	Signed	(1) The employer does not elect the employers’ liability coverage.	David Chan	Davidchan8873@gmail.com	Business Partner	West Des Moines	IA	United States	Saketh Mahavadi	Ahnaf Yeasin	Signed
303	2020-10-31 13:11	Anonymous (not verified)	173.17.230.149	Absolute Construction	Limited Liability Partnership	135 main street, 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.	2020-10-31	James Nelson	jamesnelson1983@gmail.com	Carlisle	Warren	Iowa	Joe Simpson	Alex Vanderbeek	Signed	(1) The employer does not elect the employers’ liability coverage.	James Nelson	jamesnelson1983@gmail.com	self	Carlisle	Warren	Iowa	Joe Simpson	Alex Vanderbeek	Signed
1965	2023-12-22 10:23	Anonymous (not verified)	94.188.207.229	Shawn Cooney	Proprietorship	4425 Ne 34th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-22	Shawn Nelson Cooney	shawncooney59@gmail.com	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Cooney	shawncooney59@gmail.com	Myself	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed
415	2021-03-01 17:06	Anonymous (not verified)	208.126.61.78	Fryes Tree Service	Proprietorship	P.O. Box 244 Webster City, IA 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-01	Don Johnson	fts.don@gmail.com	Webster City	Hamilton	IA	Jenna Shaw	Tim Turner	Signed	(1) The employer does not elect the employers’ liability coverage.	Don Johnson	fts.don@gmail.com	Owner	Webster City	Hamilton	IA	Jenna shaw	Tim Turner	Signed
2077	2024-03-06 11:08	Anonymous (not verified)	94.188.205.177	Randy's all Right painting	Proprietorship	24531n.ave Dallas center iowa po 445	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-06	David keasey	keaseyshideaway@gmail.com	Dallas center	Dallas	Iowa	Angela Johnston	Robin Vilz	Signed	(1) The employer does not elect the employers’ liability coverage.	David keasey	keaseyshideaway@gmail.com	Self	Dallas center	Dallas	Iowa	Angela Johnston	Robin Volz	Signed
527	2021-05-20 07:54	Anonymous (not verified)	66.43.242.142	mcconnells custom construction	Proprietorship	1074 240th 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	John McConnell	jnkatmcc@netins.net	jefferson	greene	ia	Jordan Hostetler	Mark Aspengren	Signed	(1) The employer does not elect the employers’ liability coverage.	McConnell's Custom Construction	jnkatmcc@netins.net	owner	jefferson	greene	ia	Jordan Hostetler	Mark Aspengren	Signed
2189	2024-04-29 09:23	Anonymous (not verified)	94.188.207.225	Sals Home Improvements LLC	Limited Liability Company	3750 NW Maple Ct Ankeny IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Salvador Gomez	salvadorg27@hotmail.com	Ankeny	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Salvador Gomez	salvadorg27@hotmail.com	Self	Ankeny	Polk	Iowa	Fabiola Palomares	Nathan Miller	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
942	2022-03-02 18:52	Anonymous (not verified)	173.16.196.70	Mason Cooper	Limited Liability Company	4213 Southwest 23rd Place	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-02	Mason Cooper	koupenc5@icloud.com	Des Moines	Polk	IA	Savannah Cooper	Norman Weathers	Signed	(1) The employer does not elect the employers’ liability coverage.	Mason Cooper	koupenc5@icloud.com	Myself	Des Moines	Polk	IA	Savannah Cooper	Norman Weathers	Signed
751	2021-11-16 15:51	Anonymous (not verified)	166.181.83.87	Dylan Wilson SMS & More	Proprietorship	7500 25th Milan IL 61264	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-16	Dylan Wilson	doe33843@gmail.com	Milan	Rock Island	IL	Jamie Short	Brett Dawson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Groech	wilsoncrazy@gmail.com	Grandmother	Moline	Rock Island	IL	Jamie Short	Brett Dawson	Signed
1054	2022-04-15 15:05	Anonymous (not verified)	173.23.251.188	Integrity Design & Development, LLC	Limited Liability Company	810 NW Logan St Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-15	Jerry Houk	integrity.design.development@gmail.com	Ankeny	Polk	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Integrity Design & Development, LLC	integrity.design.development@gmail.com	owner	Ankeny	Polk	Iowa	Tara Murphy	Mike Ryerson	Signed
863	2022-01-27 12:13	Anonymous (not verified)	174.198.81.166	Big Bear Construction llc	Limited Liability Company	4508 Hiawatha Ave ne Cedar Rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-27	Kevin Paul Becker jr	kbeckerbbc@gmail.com	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Allen Becker	mike4bbc@gmail.com	Brother/Partner	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed
1166	2022-06-23 09:44	Anonymous (not verified)	74.84.106.106	alan squires	Proprietorship	702 2nd ave sw #4	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-23	alan squires	shanesq411@gmail.comm	altoona	polk	iowa	TIna Owens	Rita Littell	Signed	(1) The employer does not elect the employers’ liability coverage.	alan squires	shanesq411@gmail.com	self	altoona	polk	iowa	Tina Owens	Rita Littell	Signed
1278	2022-08-22 12:15	Anonymous (not verified)	75.162.65.221	Skyler Thayer	Proprietorship	719 34th St, West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Skyler Thayer	thayerskyler@gmail.com	West Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	Skyler Thayer	thayerskyler@gmail.com	Self	West Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	Signed
1390	2022-12-12 10:27	Anonymous (not verified)	97.125.170.79	Norwalk Cleaning Servicesw	Limited Liability Company	520 W High 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.	2022-12-12	Jacob Hibbert	Maryhib@icloud.com	Norwalk	IA	United States	Kyle Grandstaff	Nicole Nichols	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Hibbert	maryhib@icloud.com	Self	Norwalk	Warren	United States	Kyle Grandstaff	Nicole Nichols	Signed
1502	2023-03-07 12:40	Anonymous (not verified)	94.188.205.177	Joseph Martin	Limited Liability Company	P O Box 277 Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Joseph Martin	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Al's Roofing LLC	darrele@ciains.biz	Member	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chrus Fye	Signed
1614	2023-04-27 15:18	Anonymous (not verified)	94.188.205.177	Crawford Construction Services LLC	Limited Liability Company	1018 Creston Ave, Des Moines, Ia 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	Casey D Crawford	crawfordcasey8824@gmail.com	Des Moines	Polk	Iowa	Nicole Powell	Steve Crawford	Signed	(1) The employer does not elect the employers’ liability coverage.	Casey D Crawford	crawfordcasey8824@gmail.com	Owner	Des Moines	Polk	Iowa	Nicole Powell	Steve Crawford	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
95	2020-03-18 14:47	Anonymous (not verified)	173.24.186.251	Layton C. Vick II dba Layton's Backhoe Service	Proprietorship	PO Box 652 / Spirit Lake, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-18	Layton Clarence VIck II	lcvii2@gmail.com	Lake Park	Dickinson	Iowa	Daniel Reimers	Marcus VanKleek	Signed	(1) The employer does not elect the employers’ liability coverage.	Layton C. Vick II	lcvii2@gmail.com	Owner	Lake Park	Dickinson	Iowa	Daniel Reimers	Marcus VanKleek	Signed
207	2020-07-16 13:05	Anonymous (not verified)	173.16.140.254	Steve Kennedy	Proprietorship	5108 SW 13th 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.	2020-07-16	Steve Kennedy	stevekennedy@gmail.com	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Kennedy	stevekennedy007@gmail.com	Owner	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed

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