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:
604	2021-08-14 11:18	Anonymous (not verified)	69.54.119.134	Robert Curry	Limited Liability Company	10759 S 96th Ave W Prairie City IA 50228	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-14	Bob Curry	Gardengal4205@gmail.com	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Curry	Gardengal4205@gmail.com	Self	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed
605	2021-08-16 16:06	Anonymous (not verified)	67.55.155.46	COMPLETE CONSTRUCTION SERVICES LLC	Limited Liability Company	718 FOX RUN	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-16	DAVID BOWER	BOWERD@OSKYCSD.ORG	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed	(1) The employer does not elect the employers’ liability coverage.	DAVID BOWER	BOWERD@OSKYCSD.ORG	PRESIDENT	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed
606	2021-08-17 12:25	Anonymous (not verified)	69.57.199.231	Precision Painting	Proprietorship	507 Broad St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed
607	2021-08-17 12:31	Anonymous (not verified)	69.57.199.231	Precsion Painting	Proprietorship	507 Broad 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.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(1) The employer does not elect the employers’ liability coverage.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed
608	2021-08-17 21:35	Anonymous (not verified)	50.82.65.174	33z Racing, LLC	Limited Liability Company	307 N Park Ave, New Sharon, IA. 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-17	James D VanderBeek	jvanderbeek@plbci.com	New Sharon	Mahaska	IA	Barbara M VanderBeek	Zackery James VanderBeek	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara M VanderBeek	bvanderbeek33z@gmail.com	Spouse	New Sharon	Mahaska	IA	James D VanderBeek	Zackery J VanderBeek	Signed
609	2021-08-17 21:42	Anonymous (not verified)	50.82.65.174	33z Racing, LLC	Limited Liability Company	307 N Park Ave, New Sharon, IA. 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-17	Zackery James VanderBeek	zackvanderbeek@gmail.com	New Sharon	Mahaska	IA	Barbara M VanderBeek	James. VanderBeek	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara M VanderBeek	bvanderbeek33z@gmail.com	Mother	New Sharon	Mahaska	IA	James D VanderBeek	Barbara M VanderBeek	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
611	2021-08-19 15:23	Anonymous (not verified)	97.125.53.119	Rogelio Lopez Casillas	Proprietorship	1175 Office Park Road Apt 109 WDM, Iowa 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.	2021-08-21	Rogelio Lopez Casillas	deb@piciowa.com	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Rogelio Lopez Casillas	deb@piciowa.com	subcontractor	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed
612	2021-08-19 21:50	Anonymous (not verified)	50.82.65.174	33z Racing,, LLC	Limited Liability Company	307 N Park Ave, New Sharon, Iowa 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	James Dean VanderBeek	jvanderbeek@plbco.com	New Sharon	Mahaska	Iowa	Margaret Ratcliff	Billy Blake	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara M VanderBeek	bvanderbeek33z@gmail.com	Spouse	New Sharon	Mahaska	Iowa	Margaret Ratcliff	Billy Blake	Signed
613	2021-08-19 21:54	Anonymous (not verified)	50.82.65.174	33z Racing, LLC	Limited Liability Company	307 N Park Ave, New Sharon, Iowa 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Zackery J VanderBeek	zackvanderbeek@gmail.com	New Sharon	Mahaska	IA	Margaret Ratcliff	Billy Blake	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara M VanderBeek	bvanderbeek33z@gmail.com	Mother	New Sharon	Mahaska	IA	Margaret Ratcliff	Billy Blake	Signed
614	2021-08-20 12:20	Anonymous (not verified)	172.58.235.242	Darren Qualls	Proprietorship	1515 Dewitt St. Ellsworth. IA 50075	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Darren Wade Qualls	d.qualls@outlook.com	Ellsworth	Hamilton	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed	(1) The employer does not elect the employers’ liability coverage.	Darren Wade Qualls	d.qualls@outlook.com	Self/Proprietor	Ellsworth	IA	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed
615	2021-08-20 16:22	Anonymous (not verified)	50.81.152.147	CPIA Home Specialists LLC	Limited Liability Company	1214 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.	2021-08-20	Melvin Benitez	Benitezmelvin0@gmail.com	Des Moines	Iowa	United States	Salvador Benitez	Zoila Benitez	Signed	(1) The employer does not elect the employers’ liability coverage.	Melvin Benitez	Benitezmelvin0@gmail.com	Owner	Des Moines	Iowa	United States	Salvador Benitez	Zoila Benitez	Signed
616	2021-08-23 13:14	Anonymous (not verified)	173.25.153.19	Levon	Proprietorship	210 S 41st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Levon shheba	sheebalevon@gmail.com	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed	(1) The employer does not elect the employers’ liability coverage.	Levon sheeba	sheebalevon@gmail.com	Myself	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed
617	2021-08-23 13:58	Anonymous (not verified)	172.58.84.152	Jose barrientos	Proprietorship	1844 n tony ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-23	Jose Barrientos	70barrientos70@gmail.com	Wichita	Sedwick	Kansas	Roberto valle	Juan lopez	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jose barrientos	70barrientos70@gmail.com	Employer	Wichita	Sedwick	Kansas	Vladimir faustino	Rene Grande	Signed
618	2021-08-23 15:17	Anonymous (not verified)	173.17.131.91	Leaffilter North of Iowa, LLC	Proprietorship	5650 NW Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Jorge Meraz	jmaraz961@gmail.com	2906 e madison avenue	Des moines	IA	Jisel chaves	Melvin arevalo	Signed	(1) The employer does not elect the employers’ liability coverage.	Jorge meraz	jmeraz961@gmail.com	Self	Des moines	Des moine	IA	Jusel chavez	Melvin arevalo	Signed
619	2021-08-25 14:31	Anonymous (not verified)	192.154.15.2	MAV Restorations LLC	Limited Liability Company	5461 Meadow Ct, Asbury, IA 52002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-25	Matthew Vaske	mlvaske@gmail.com	Asbury	Dubuque	IA	Randi Taylor	Carla Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Vaske	mlvaske@gmail.com	Self	Asbury	Dubuque	IA	Randi Taylor	Carla Martin	Signed
620	2021-08-26 16:26	Anonymous (not verified)	75.162.146.246	Daniel Meza Reyes	Proprietorship	1640 E Army Post RD Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Daniel Meza Reyes	danielmr9247@gmail.com	Des Moines	polk	IA	Yolanda Mendoza	Liliana Sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Meza Reyes	danielmr9247@gmail.com	self	Des Moines	polk	IA	Yolanda Mendoza	Liliana Sanchez	Signed
621	2021-08-27 16:11	Anonymous (not verified)	71.39.227.238	DOUG WEISS DBA DIRTWORKS	Proprietorship	23966 MIDLAND TRAIL, 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.	2021-08-27	DOUG WEISS	EWEISSN03.EW@GMAIL.COM	DALLAS CENTER	DALLAS	IOWA	DON RICHARDSON	ABBEY LUELLEN	Signed	(1) The employer does not elect the employers’ liability coverage.	DOUG WEISS	EWEISSN03.EW@GMAIL.COM	SELF	DALLAS CENTER	DALLAS	IOWA	DON RICHARDSON	ABBEY LUELLEN	Signed
622	2021-08-27 16:12	Anonymous (not verified)	71.39.227.238	DOUG AND ELLEN WEISS DBA DIRTWORKS	Proprietorship	23966 MIDLAND TRAIL, 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.	2021-08-27	ELLEN WEISS	EWEISSN03.EW@GMAIL.COM	DALLAS CENTER	DALLAS	IOWA	DON RICHARDSON	ABBEY LUELLEN	Signed	(1) The employer does not elect the employers’ liability coverage.	ELLEN WEISS	EWISSN03.EW@GMAIL.COM	SELF	DALLAS CENTER	DALLAS	IOWA	DON RICHARDSON	ABBEY LUELLEN	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
624	2021-08-30 15:53	Anonymous (not verified)	174.253.66.113	Leaf Home Solutions LLC	Limited Liability Company	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.	2021-08-30	Chad York	Cyork027@gmail.com	Davenport	Scott	Iowa	Chad York	Adam Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Coleman	ARColeman@leafhome.com	Recruiter	Hudson	Summit	Ohio	Chad York	Adam Coleman	Signed
625	2021-08-30 20:39	Anonymous (not verified)	173.16.140.101	Phthalo Consulting LLC	Limited Liability Company	2917 47th St, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Angela Stone-Wiegert	angela@phthaloconsulting.com	Des Moines	Polk	Iowa	Sonya Shippy	Kenny Shippy	Signed	(1) The employer does not elect the employers’ liability coverage.	Angela Stone-Wiegert	angela@phthaloconsulting.com	Owner	Des Moines	Polk	Iowa	Sonya Shippy	Kenny Shippy	Signed
626	2021-08-31 11:39	Anonymous (not verified)	166.181.81.253	Birds landscape maintenance LLC	Limited Liability Company	1307 w 4th st south	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-31	Michael Alan bird	birdslawn@hotmail.com	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Alan bird	birdslawn@hotmail.com	Same - owner	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed
627	2021-08-31 16:12	Anonymous (not verified)	173.18.16.129	D's Home Improvement	Limited Liability Company	665 27th St Des Moines IA 50312	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-31	Dustin Mitchell	dustinmitchell8855@gmail.com	Des Moines	Polk	Iowa	Lesa Reeves	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Mitchell	dustinmitchell8855@gmail.com	Owner	Des Moines	Polk	IA	Lesa Reeves	Kelly Coluzzi	Signed
628	2021-09-01 09:39	Anonymous (not verified)	204.155.61.217	Utzinger Epoxy & Concrete, LLC	Limited Liability Company	1595 Highway 1 Washington, Iowa 52353	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Troy Utzinger	tbutzinger99@kctc.net	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Utzinger	tbutzinger99@kctc.net	owner	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
629	2021-09-01 09:44	Anonymous (not verified)	204.155.61.217	Thrapp Electric	Proprietorship	708 2nd Street Wellman, Iowa 52356	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Jay Thrapp	socketman5555@hotmail.com	Wellman	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Thrapp	socketman5555@hotmail.com	Owner	Wellman	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
630	2021-09-01 19:29	Anonymous (not verified)	97.125.133.79	Aaron J. Rosenbaum	Proprietorship	2005 Pine St, Granger, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Aaron J. Rosenbaum	aabaum7@gmail.com	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Rosenbaum	aabaum7@gmail.com	self	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed
631	2021-09-02 22:46	Anonymous (not verified)	173.23.144.4	Lopez Framing LLC	Limited Liability Company	566 walker 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.	2021-09-02	Diana A Garcia Lopez	lopezframing0702@gmail.com	Des moines	Polk	Iowa	Marlon Lopez	Jennifer Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Diana A Garcia Lopez	lopezframing0702@gmail.com	Owner	Des moines	Polk	Iowa	Marlon Lopez	Jennifer Reyes	Signed
632	2021-09-07 13:42	Anonymous (not verified)	50.82.130.211	Thomas Mann	Proprietorship	401 Miners Street, Parkersburg, 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.	2021-09-09	Thomas Mann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Mann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
633	2021-09-08 10:35	Anonymous (not verified)	208.95.1.97	BAJ Flooring, LLC	Limited Liability Company	31533 Castle Ct. Dyersville, IA. 52040-7600	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2021-09-08	Brian Jacque	JacqueBrian18@gmail.com	Dyersville	Dubuque	Iowa	Stephen J. Schluter	Paula Fitzgerald	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Brian A. Jacque	JacqueBrian18@gmail.com	LLC MEMBER	Dyersville	DUBUQUE	IOWA	Stephen J. Schlueter	Stephen J. Schlueter	Signed
634	2021-09-10 13:41	Anonymous (not verified)	173.23.145.231	julio medina	Proprietorship	609 boyd 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.	2021-09-10	julio medina	medinajulio10001@gmail.com	des moines	polk	iowa	jose rivas	Virginia Gomez	Signed	(1) The employer does not elect the employers’ liability coverage.	Julio Medina	medinajulio10001@gmail.com	owner	des moines	polk	iowa	jose Rivas	Virginia Gomez	Signed
635	2021-09-10 13:41	Anonymous (not verified)	166.181.84.226	JZH Roofing Specialists LLC	Limited Liability Company	2127 Swan Dr, Norwalk, Iowa. 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.	2021-09-10	Jayme Alexander Christian Heiselman	wrkhrd2plyhrd04@gmail.com	Norwalk	Warren	Iowa	Melanie Handy	Jesse Hagge	Signed	(1) The employer does not elect the employers’ liability coverage.	Jayme Alexander Christian Heiselman	wrkhrd2plyhrd04@gmail.com	Single member	Norwalk	Warren	Iowa	Melanie Handy	Jesse Hagge	Signed
636	2021-09-10 14:56	Anonymous (not verified)	173.19.179.111	SHANNON SUNDINE	Proprietorship	513 16TH ST SPIRIT LAKE IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-10	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
637	2021-09-10 15:15	Anonymous (not verified)	204.155.61.217	Duwa Waterproofing LLC	Limited Liability Company	1548 150th 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.	2021-09-10	Stacy Duwa	duwawaterproofing@gmail.com	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	owner	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed
638	2021-09-13 09:18	Anonymous (not verified)	74.84.91.178	Thomas Tremble	Proprietorship	1209 University Avenue, Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-09	Thomas Tremble	TJTremble21@gmail.com	Dubuque	Dubuque	Iowa	Gabe Drewelow	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Tremble	TJTremble21@gmail.com	self	Dubuque	Dubuque	Iowa	Gabe Drewelow	Derrick Parsons	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
640	2021-09-16 22:43	Anonymous (not verified)	97.125.255.204	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, Iowa 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.	2021-09-16	Mackinley Charles Morgan	Morgangroupllc@gmail.com	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Mackinley Charles Morgan	Morgangroupllc@gmail.com	Owner of company	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed
641	2021-09-17 09:16	Anonymous (not verified)	72.255.121.118	Osman Gonzalez-Sarceno	Proprietorship	1403 Aspen Dr Adel, 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.	2021-09-17	Osman Gonzalez-Sarceno	workorders@shoproyalflooring.com	Des Moines	Polk	IA	Melissa Bolanos	Brianna Fuller	Signed	(1) The employer does not elect the employers’ liability coverage.	Osman Gonzalez-Sarceno	workorders@shoproyalflooring.com	Owner	Des Moines	Polk	Iowa	Melissa Bolanos	Brianna Fuller	Signed
642	2021-09-17 11:09	Anonymous (not verified)	167.142.95.56	Preferred Properties of Iowa, Inc.	Limited Liability Company	500 W. Temple 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.	2021-09-17	Daniel Zech	dan.ppi@gmail.com	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Zech	dan.ppi@gmail.com	Owner	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed
643	2021-09-17 11:17	Anonymous (not verified)	167.142.95.56	Preferred Properties of Iowa, Inc.	Limited Liability Company	500 W. Temple St., Lenox, IA 50851	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-17	Mark Pearson	mdpearson88@gmail.com	Corning	Adams	Iowa	Ron Travis	Maury Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Zech	dan.ppi@gmail.com	Owner	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed
644	2021-09-17 11:20	Anonymous (not verified)	167.142.95.56	Preferred Properties of Iowa, Inc.	Limited Liability Company	500 W. Temple St., Lenox, IA 50851	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-17	Brennan Kester	mdpearson88@gmail.com	Corning	Taylor	Iowa	Ron Travis	Maury Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Zech	dan.ppi@gmail.com	owner	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed
645	2021-09-18 09:47	Anonymous (not verified)	208.68.114.238	CHL Roofing & Siding Inc	Proprietorship	509 1/2 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.	2021-09-18	Fabian Galvan Rodriguez	fgalvanglez14@gmail.com	West Liberty	Muscatine	Iowa	Karina A Beltran	Nereida Velez	Signed	(1) The employer does not elect the employers’ liability coverage.	Fabian Galvan Rodriguez	fgalvanglez14@gmail.com	Self	West Liberty	Muscatine	Iowa	Karina A Beltran	Nereida Velez	Signed
646	2021-09-20 08:54	Anonymous (not verified)	173.24.107.209	QCA Professional Contractors	Limited Liability Company	3314 67th Ave, Moline, IL. 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-20	Allan Celada	allancelada@qcaprocontractors.com	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Allan Celada	allancelada@qcaprocontractors.com	self	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	Signed
647	2021-09-20 10:37	Anonymous (not verified)	173.29.34.49	Brandon Jones	Proprietorship	2043 3x 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.	2021-09-20	Brandon Dederick Jones	Kaleb0430jones@gmail.com	East Moline	United States	Illinois	Brandon Jones	Brandon Jones	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Dederick Jones	Kaleb0430jones@gmail.com	self	East Moline	United States	Illinois	Brandon Jones	Brandon Jones	Signed
648	2021-09-21 10:03	Anonymous (not verified)	97.125.32.164	Manuel Morales	Proprietorship	1302 13th St Des Moines, Iowa 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-15	Manuel Morales	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Manuel Morales	deb@picowa.com	subcontractor	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
649	2021-09-21 13:15	Anonymous (not verified)	208.126.118.26	Wade Smith DBA WADA Farms	Proprietorship	2428 270th st, Grand Mound, IA 52751	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2021-09-21	Wade Smith	wade.smith1110@gmail.com	Grand Mound	Clinton	Iowa	Megan Fuglsang	Jenny Gordon	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Wade Smith	wade.smith1110@gmail.com	self	Grand Mound	Clinton	Iowa	Megan Fuglsang	Jenny Gordon	Signed
650	2021-09-22 20:46	Anonymous (not verified)	174.198.68.116	Freedom field services	Limited Liability Company	6285 n 67 ave w baxter iowa 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
651	2021-09-22 21:05	Anonymous (not verified)	174.198.68.116	Freedom field services LLC	Limited Liability Company	6285 n 67 ave w. BAXTER IOWA 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
652	2021-09-22 21:52	Anonymous (not verified)	209.152.66.250	Robert Stutzman	Limited Liability Company	33784 Hwy 22 Keota, IA 25548	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	Robert L Stutzman	bnbstutzman@gmail.com	Keota	Keokuk	Iowa	Jo Edgington	Amber Gent	Signed	(1) The employer does not elect the employers’ liability coverage.	Sandra K Stutzman	iafarmgirl90@gmail.com	Daughter	Keota	Keokuk	Iowa	Jo Edgington	Amber Gent	Signed
653	2021-09-23 15:03	Anonymous (not verified)	72.46.189.33	Feldkamp Farms Inc	Partnership	5382 170th St Sibley IA 51249	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-23	Harold P Feldkamp	joan@ellerbroekandassociates.com	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed	(1) The employer does not elect the employers’ liability coverage.	James Wade Ellerbroek Jr	WADE@ELLERBROEKANDASSOCIATES.COM	Agent only	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed
654	2021-09-24 15:08	Anonymous (not verified)	199.247.64.87	Steve Porter DBA Precision Striping	Proprietorship	408 Embassy Ct. Sergeant Bluff, IA 51054	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-23	Steve Porter	steve.porter2710@gmail.com	Sergeant Bluff	Woodbury	Iowa	Josh Nichols	Steve Porter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jana Reich	JNeuzil@reichpainting.com	Office Manager	Sioux City	Woodbury	Iowa	Josh Nichols	Steve Porter	Signed
655	2021-09-24 15:28	Anonymous (not verified)	67.212.111.166	S Miller Painting LLC	Limited Liability Company	1135 Barnett Drive, 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.	2021-09-24	Steven David Miller	stevendm24@hotmail.com	Cedar Falls	Black Hawk	Iowa	Steve Koger	Mark Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Allen koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk	Iowa	Steve Koger	Mark Miller	Signed
656	2021-09-25 09:20	Anonymous (not verified)	173.20.172.87	Daugherty Construction LLC	Limited Liability Company	1985 SE Willow Brook Dr, Waukee, 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.	2021-09-25	Joseph Ryan Daugherty	jdaugherty1024@yahoo.com	Waukee	Dallas	Iowa	Sarah Lynn Daugherty	Timothy Joe Daugherty	Signed	(1) The employer does not elect the employers’ liability coverage.	Daugherty Construction LLC	jdaugherty1024@yahoo.com	Owner/President	Waukee	Dallas	Iowa	Sarah Lynn Daugherty	Timothy Joe Daugherty	Signed
657	2021-09-27 13:55	Anonymous (not verified)	167.142.136.87	Crosser Electric,Inc	Partnership	PO Box 204 Eldora, Iowa 50627	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-27	Marlyn D Crosser	vhalvorsen@aol.com	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed	(1) The employer does not elect the employers’ liability coverage.	Vicki Halvorsen	vhalvorsen@aol.com	Partner andf sec/treasurer	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed
658	2021-09-27 14:01	Anonymous (not verified)	167.142.136.87	Crosser Electric, Inc	Partnership	PoBox 204 Eldora, Iowa 50627	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-27	Victoria Halvorsen	vhalvorsen@aol.com	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed	(1) The employer does not elect the employers’ liability coverage.	Victoria or Vicki Halvorsen	vhalvorsen@aol.com	Partner sec/treasure	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed
659	2021-09-28 11:02	Anonymous (not verified)	172.58.83.48	Sean Goodwin	Limited Liability Company	8843 primrose lane Clive IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-28	Sean Goodwin	simplemanmx@gmail.com	Clive	IA	United States	Kaitlyn meier	Tina meier	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Goodwin	simplemanmx@gmail.com	Self	Clive	Polk	Iowa	Kaitlyn meier	Tina meier	Signed
660	2021-09-30 14:15	Anonymous (not verified)	172.58.86.219	LeafFilter	Limited Liability Company	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.	2021-09-30	Mohammed Albayati	mmm2002faris@yahoo.com	West Des Moines	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Albayati	albayatim28@gmail.com	Employee	Grimes	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed
661	2021-10-01 09:00	Anonymous (not verified)	71.34.184.201	Jose Tavares	Proprietorship	1175 Office Park Rd Apt 109 WDM 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.	2021-09-24	Jose Tavares	deb@piciowa.com	1175 Office Park Rd Apt 109 WDM IA 50266	Polk	Iowa	Martin Pinon	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Tavares	deb@piciowa.com	self	WDM	Polk	IA	Martin Pinon	Debra Stratton	Signed
662	2021-10-01 16:05	Anonymous (not verified)	174.242.224.18	Troy bryan	Limited Liability Company	2800 68th st urbandale Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-01	Troy bryan	tbryan0015@gmail.com	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Troy bryan	tbryan0015@gmail.com	Owner	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed
663	2021-10-04 09:45	Anonymous (not verified)	166.181.80.1	Matthew Winters	Proprietorship	9220 Summit Dr Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-04	Matthew Winters	mattwinters55@gmail.com	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Winters	mattwinters55@gmail.com	Self	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed
664	2021-10-05 15:01	Anonymous (not verified)	174.242.226.8	New Face Renovations	Limited Liability Company	3563 Richland Circle Van Meter, 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.	2021-10-05	Darin Benjamin Davis	newfacereno@gmail.com	Van Meter	Dallas	Iowa	Ryan Young	Betsy Davis	Signed	(1) The employer does not elect the employers’ liability coverage.	Renda Building	megemo@commdatalink.com	Installer	Grimes	Polk	Iowa	Ryan Young	Betsy Davis	Signed
665	2021-10-06 09:22	Anonymous (not verified)	192.96.173.171	Michael Childers	Proprietorship	21 N.6th street savanna Illinois	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-06	Michael Childers	peddler73@hotmail.com	Savanna	Carroll	Illinois	Brandy arnold	Jordan nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas city	Clay	Mo	Jordan nisiewicz	Brandy arnold	Signed
666	2021-10-07 08:12	Anonymous (not verified)	208.126.166.149	Toribio Construction LLC	Limited Liability Company	107 W Maxson 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.	2020-10-07	Jose Toribio	osorioabigail0224@gmail.com	West Liberty	Muscatine	IA	Anthony Johnson	Abigail Osorio	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Toribio	osorioabigail0224@gmail.com	Owner	West Liberty	Muscatine	IA	Anthony Johnson	Abigail Osorio	Signed
667	2021-10-11 19:33	Anonymous (not verified)	104.166.240.24	FS Custom Flooring	Limited Liability Company	5729 NW 92nd 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.	2021-10-11	Filip Sakanovic	filip@fscustomflooring.com	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	FS Tiling and Ceramics	filip@fscustomflooring.com	N/A	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	Signed
668	2021-10-12 16:11	Anonymous (not verified)	173.18.22.217	Mo's Cleaning LLC	Limited Liability Company	1412 E 23rd St Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-12	Melissa Jones	commcleanwithme123@gmail.com	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Jones	commcleanwithme123@gmail.com	Owner	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed
669	2021-10-13 08:24	Anonymous (not verified)	64.191.11.62	E360 Building Company, Inc.	Proprietorship	PO Box 363, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-13	Mark Miller	mark@e360buildingco.com	Cedar Falls	Black Hawk	Iowa	Laetyn Miller	Grant Williamson	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Miller	markm@cfu.net	Self	Cedar Falls	Black Hawk	Iowa	Laetyn Miller	Grant Williamson	Signed
670	2021-10-13 12:30	Anonymous (not verified)	173.19.179.111	MULLER TRANSPORT LLC	Limited Liability Company	2083 260TH ST MILFORD, IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-13	PAUL MULLER	MULLERTANSPORTLLC@GMAIL.COM	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	PAUL MULLER	JOEL@WALKERINSURANCEIA.COM	SELF	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
671	2021-10-13 15:00	Anonymous (not verified)	173.23.180.179	Larry and Company Inc.	Proprietorship	7239 Osage Road, Waterloo, Iowa 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-13	Larry Rust	larryandcoinc@hotmail.com	Waterloo	Black Hawk	Iowa	Lisa Kay Buls	Kevin Thomas Buls	Signed	(1) The employer does not elect the employers’ liability coverage.	Larry Alan Rust	larryandcoinc@hotmail.com	Self	Waterloo	Black Hawk	Iowa	Lisa Kay Buls	Kevin Thomas Buls	Signed
672	2021-10-13 16:05	Anonymous (not verified)	75.162.218.218	Arturos Interiors LLC	Limited Liability Company	3305 se 22nd apt 15 Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-29	Arturo mejia	arturomcruz20@hotmail.com	Des Moines	polk	IA	yolanda mendoza	liliana sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Arturo Mejia	arturomcruz20@hotmail.com	member	Des Moines	polk	IA	Yolanda Mendoza	lialiana sanchez	Signed
673	2021-10-14 07:15	Anonymous (not verified)	97.125.239.203	Complete tile llc	Limited Liability Company	875 se gateway drive #311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-14	Nedzad mustafic	completetile1@gmail.com	Grimes	Usa	Iowa	Enesa Mustafic	Edina avdic	Signed	(1) The employer does not elect the employers’ liability coverage.	Nedzad Mustafic	completetile1@gmail.com	Owner	Grimes	Usa	Iowa	Enesa mustafic	Edina avdic	Signed
674	2021-10-15 09:43	Anonymous (not verified)	173.29.63.3	Peter Hawley	Proprietorship	524 n galena ave, Wyoming Illinois 61491	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-15	Peter Anthony Hawley	hawleypete801@gmail.com	Wyoming	Stark	Illinois	Elizabeth Doreen Hawley	Ian Matthew Esmoil	Signed	(1) The employer does not elect the employers’ liability coverage.	Peter Anthony Hawley	hawleypete801@gmail.com	Self	Wyoming	Stark	IL	Elizabeth Doreen Hawley	Ian Matthew Esmoil	Signed
675	2021-10-15 11:22	Anonymous (not verified)	75.162.156.37	MCG FLOORING, LLC	Limited Liability Company	2115 CARPENTER AVE 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.	2021-10-15	GABRIELA GOMEZ	MCGFLOORINGLLC@GMAIL.COM	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(1) The employer does not elect the employers’ liability coverage.	MCG FLOORING, LLC	MCGFLOORINGLLC@GMAIL.CON	OWNER	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
676	2021-10-15 11:29	Anonymous (not verified)	75.162.156.37	MCG FLOORING, LLC	Limited Liability Company	2115 CARPENTER AVE 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-15	MANUEL CONTRERAS BERNAL	MCGFLOORINGLLC@GMAIL.COM	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	MCG FLOORING, LLC	MCGFLOORINGLLC@GMAIL.CON	OWNER	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
677	2021-10-18 11:09	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer 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.	2021-10-18	Marcie R Gaylord	avisburlington@hotmail.com	Fort Madison	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	Lee	Iowa	Kim Delap	Teri Coleman	Signed
678	2021-10-18 11:26	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer 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.	2021-10-18	Linda Hunter	whitandpayt@gmail.com	Burlington	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	IA	United States	Kim Delap	Teri Coleman	Signed
679	2021-10-18 13:14	Anonymous (not verified)	173.18.22.217	Xscape Extreme Hard & Landscape	Proprietorship	3215 E 25th CT Bldg Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Mike Tapper	Tapper4981@gmail.com	Des Moines	Polk	IA	Lesa Dillon	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Tapp	Tapper4981@gmail.com	Owner	Des Moines	Des Moines	IA	Lesa Dillon	Kelly Coluzzi	Signed
680	2021-10-18 13:58	Anonymous (not verified)	166.181.86.88	Gerald Jerome	Proprietorship	2668 Wapsi Ridge Dr. Walker, IA 52352	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Gerald Jerome	geraldjerome373@ymail.com	Walker	IA	United States	Benjamin J Barkalow	James M. Barkalow	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerald Jerome	geraldjerome373@ymail.com	Self employed	Walker	Linn	Iowa	Benjamin J Barkalow	James M Barkalow	Signed
681	2021-10-19 15:44	Anonymous (not verified)	65.144.174.26	Humberto Albino	Proprietorship	3914 Aurora Ave Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-19	Humberto Albino	albinohumberto73@gmail.com	Des Moines	Polk	Iowa	Miguel Albino	Jesus Albino	Signed	(1) The employer does not elect the employers’ liability coverage.	Humberto Albino	albinohumberto73@gmail.com	Owner	Des Moines	Polk	Iowa	Miguel Albino	Jesus Albino	Signed
682	2021-10-19 16:15	Anonymous (not verified)	65.144.174.26	BBR Tile and Professional Installation LLC	Proprietorship	903 School Ave 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.	2021-10-19	Bertin Baltazar	baltarey2009@gmail.com	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Bertin Baltazar	baltarey2009@gmail.com	Owner	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed
683	2021-10-20 09:39	Anonymous (not verified)	173.23.253.122	Superior Floors	Limited Liability Company	704 41st 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.	2021-10-20	Ron Shannon	ronshannon3831@gmail.com	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Shannon	ronshannon3831@gmail.com	Self	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed
684	2021-10-20 13:25	Anonymous (not verified)	65.144.174.26	A and H Home Improvement	Limited Liability Company	600 NE 64th 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.	2021-10-20	Ivan A. Abel	aandhhomeimprovement@gmail.com	Des Moines	Polk	Iowa	Ken Krogman	Bruce Baumgarn	Signed	(1) The employer does not elect the employers’ liability coverage.	Ivan A. Abel	aandhhomeimprovement@gmail.com	Self	Des Moines	Polk	Iowa	Ken Krogman	Bruce Baumgarn	Signed
685	2021-10-20 14:14	Anonymous (not verified)	65.144.174.26	william c sawhill	Proprietorship	1625 Delaware Ave, Des Moines, 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	William C Sawhill	workorders@shoproyalflooring.com	Des Moines	Polk	Iowa	Nicholas W Sawhill	Jenny M Steben	Signed	(1) The employer does not elect the employers’ liability coverage.	William C Sawhill	workorders@shoproyalflooring.com	Self	Des Moines	Polk	Iowa	Nicholas W Sawhill	Jenny M Steben	Signed
686	2021-10-20 18:43	Anonymous (not verified)	173.27.196.168	Royal Flooring	Proprietorship	11801 Hickman Rd Urbandale, IA 50323 United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Joel Cisneros	auroraramos476@gmail.com	Des Moines	Polk county	Iowa	Aurora Cisneros	Maria Arroyo	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	cisnerostile476@gmail.com	Employee	Clive	Dallas	Iowa	Aurora Cisneros	Maria Arroyo	Signed
687	2021-10-22 11:07	Anonymous (not verified)	65.144.174.26	Fernando Garcia	Proprietorship	8952 Long Meadow Dr Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Fernando Garcia	gfernando5030@gmail.com	johnston	polk	Iowa	Javier Manriquez	Josefina Chavez	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Garcia	gfernando5030@gmail.com	Owner	Johnston	Polk	Iowa	Javier Manriquez	Josefina Chavez	Signed
688	2021-10-25 10:56	Anonymous (not verified)	75.91.173.195	Ami Westcott	Proprietorship	2672 F 52 Trail Parnell, IA 52325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Ami Lynn Westcott	ami.westcott@gmail.com	Parmell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed	(1) The employer does not elect the employers’ liability coverage.	Ami Lynn Westcott	ami.westcott@gmail.com	self	Parnell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd Coralville IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	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
691	2021-10-26 14:54	Anonymous (not verified)	65.144.174.26	Alfonso Montoya	Proprietorship	2114 Nw Maple 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.	2021-10-26	Alfonso Montoya	fonzflooring@gmail.com	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Alfonso Montoya	fonzflooring@gmail.com	Owner	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed
692	2021-10-26 14:58	Anonymous (not verified)	65.144.174.26	Jake Kenney	Proprietorship	3201 Hillsdale Dr. , 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.	2021-10-26	Jacob Daniel Kenney	Jakedkenney@hotmail.com	Urbandale	Polk	Iowa	Abbey Kenney	Jory Ringler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Daniel Kenney	jakedkenney@hotmail.com	Owner	Urbandale	polk	ia	abbey kenney	jory ringler	Signed
693	2021-10-26 15:03	Anonymous (not verified)	65.144.174.26	Diamante Tile	Proprietorship	1403 Aspen Dr Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Octavio Bermudez	aerosobo@gmail.com	Des Moines	Dallas	Iowa	Antonia Bermudez	Sofia Piatt	Signed	(1) The employer does not elect the employers’ liability coverage.	Octavio Bermudez	aerosobo@gmail.com	Owner	Adel	Dallas	Iowa	Antonia Bermudez	Sofia Piatt	Signed
694	2021-10-26 15:30	Anonymous (not verified)	65.144.174.26	Escoto Tile	Proprietorship	6820 University Ave Windsor Heights, IA 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Salvador Escoto	escototile@gmail.com	Windsor Heights	Polk	Iowa	Claudia Veronica Ojeda Escoto	Josefina Escoto	Signed	(1) The employer does not elect the employers’ liability coverage.	Salvador Escoto	escototile@gmail.com	Owner	WINDSOR HEIGHTS	Polk	Iowa	Claudia Veronica Ojeda Escoto	Josefina Escoto	Signed
695	2021-10-26 17:22	Anonymous (not verified)	208.126.118.243	Godes Farms Trucking LLC	Limited Liability Company	1698 270th 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.	2021-10-26	Mitchel R Godes	mitchelgodes@hotmail.com	Delmar	clinton	iowa	Dustin Kyarsgaard	Mitch Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchel R Godes	mitchelgodes@hotmail.com	owner	Delmar	Clinton	iowa	Dustin KKyarsgaard	Mitch Moore	Signed
696	2021-10-28 10:33	Anonymous (not verified)	173.18.85.215	Saunders Construction	Proprietorship	7304 SW 14th St Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	Charles A Saunders	charlessaunders901@gmail.com	Des Moines	IA	United States	Ramona Mitchell	Rasheedah Gasaway	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Saunders	charlessaunders901@gmail.com	Owner	Des Moines	Polk	Iowa	Ramona Mitchell	Rasheedah Gasaway	Signed
697	2021-10-28 15:30	Anonymous (not verified)	208.126.114.236	bartman express	Limited Liability Company	1976 240th st bennett iowa 52721	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	bartin joesph steines	bartmanexpress@gmail.com	bennett	cedar	iowa	Robert theordore jarrett	dana marie shipler	Signed	(1) The employer does not elect the employers’ liability coverage.	bartin joesph steines	bartmanexpress@gmail.com	self	bennett	cedar	iowa	robert theordore jarrett	dana marie shipler	Signed
698	2021-10-28 16:09	Anonymous (not verified)	71.228.88.54	Warren Nelson	Proprietorship	2525 Nebraska Street, 106, Sioux City, Iowa 51104	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	Scott D. Nelson	scottdnelson@hotmail.com	Sioux City	Woodbury	Iowa	Wallace E Sheets	Abby McDermott	Signed	(1) The employer does not elect the employers’ liability coverage.	Beth L Sheets	w143bs@verizon.net	Daughter	Sarasota	Manatee	Florida	Wallace E. Sheets	Abby McDermott	Signed
699	2021-10-28 21:28	Anonymous (not verified)	75.162.104.116	Hild Construction, LLC	Limited Liability Company	6439 NE 5th Ave, Pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	Jason Hild	dirtsailor133@gmail.com	Pleasant Hill	Iowa	United States	Scott Dart	Michael Kramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Hild	dirtsailor133@gmail.com	Self	Pleasant Hill	Polk	United States	Scott Dart	Michael Kramer	Signed
700	2021-10-29 11:04	Anonymous (not verified)	174.198.66.50	T&C Lawn Care LLC	Limited Liability Partnership	1827 Black Hawk St Waterloo IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Cody R Woodley	cody.woodley50@gmail.com	Cedar Falls	Blackhawk	Iowa	Tara R Woodley	Sara Woodley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristi S. Demuth Agency, Inc.	kdemuth@amfam.com	Client	Waverly	Bremer	Iowa	Cody R Woodley	Tyler M Croft	Signed
701	2021-10-29 18:35	Anonymous (not verified)	173.18.85.215	Saunders Construction	Proprietorship	7304 SW 14th 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.	2021-10-29	Charles Saunders	charlessaunders901@gmail.com	Des Moines	Iowa	Iowa	Ramona Mitchell	Rasheedah Gasaway	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Saunders	charlessaunders901@gmail.com	Owner	Des Moines	IA	United States	Ramona Mitchell	Rasheedah Gasaway	Signed
702	2021-11-01 09:23	Anonymous (not verified)	173.28.195.56	Garcia Snow Removal	Limited Liability Company	213 E 7th Street, West Liberty, Iowa 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.	2021-11-01	Benji A Garcia	garciabenji23@gmail.com	West Liberty	IA	Norway	Luis Ordenana-Choez	Vicente Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Benji Garcia	garciabenji23@gmail.com	Member	West Liberty	Muscatine	Iowa	Luis Ordenana-Choez	Vicente Garcia	Signed
703	2021-11-01 11:25	Anonymous (not verified)	65.144.174.26	G & D Tile	Proprietorship	2210 E Rose Ave Apt 9 Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-01	Gerson Mejia	gersonmejia25@icloud.com	Des Moines	Polk	Iowa	Katherine Castillo	Jose Leonardo	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerson Mejia	gersonmejia25@icloud.com	Owner	Des Moines	Polk	Iowa	Katherine Castillo	Jose Leonardo	Signed

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