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:
1217	2022-07-21 06:51	Anonymous (not verified)	209.152.88.53	Bullard Accounting Services, LLC	Limited Liability Company	4519 Scouts View Dr, Central City, IA 52214	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-21	Michael Bullard	mikeandkarenbullard@gmail.com	CENTRAL CITY	IA	United States	Karen Bullard	Nicole Nassif	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Bullard	mikeandkarenbullard@gmail.com	President of Company	CENTRAL CITY	IA	United States	Karen Bullard	Nicole Nassif	Signed
1228	2022-07-26 10:06	Anonymous (not verified)	173.23.93.3	Gaytan Framing LLC	Limited Liability Company	2418 East 37th Court	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-26	Jose Gaytan	jose1988.jg8@gmail.com	Des Moines	Polk	United States	CARLA C. GAYTAN	Juan Franco	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Gaytan	jose1988.jg8@gmail.com	self	Des Moines	IA	United States	CARLA C. GAYTAN	Juan franco	Signed
1235	2022-08-01 17:22	Anonymous (not verified)	129.222.1.151	KRG Gutters	Limited Liability Company	20376 Whiskey Rdg Ottumwa, Ia 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-01	Robert M Galey	rsgaley24@yahoo.com	Ottumwa	IA	United States	Stacey Galey	Kinnick Galey	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert M Galey	rsgaley24@gmail.com	Self	Ottumwa	IA	United States	Stacey Galey	Kinnick Galey	Signed
1237	2022-08-01 22:40	Anonymous (not verified)	50.80.97.239	Andy Fiala	Proprietorship	1628 34th St. NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-01	Andy W Fiala	fialaandy1@gmail.com	Cedar Rapids	IA	United States	John A Hasson	Scott M Fiala	Signed	(1) The employer does not elect the employers’ liability coverage.	Andy W Fiala	fialaandy1@gmail.com	Owner	Cedar Rapids	IA	United States	John A Hasson	Scott M Fiala	Signed
1241	2022-08-03 10:56	Anonymous (not verified)	72.169.80.108	Landon Henriksen	Proprietorship	35374 GARDEN 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-03	LANDON HENRIKSEN	HENRIKSENLK@AOL.COM	Edgewood	IA	United States	LANDON HENRIKSEN	LANDON HENRIKSEN	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	LANDON HENRIKSEN	HENRIKSENLK@AOL.COM	Same	Edgewood	IA	United States	Scott Johnson	Josh lafond	Signed
1247	2022-08-08 16:43	Anonymous (not verified)	72.13.27.236	Williams Hardwood Flooring LLC	Limited Liability Company	10359 Deer Trail	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-05	Chad Everett Williams	williamshardwood@aol.com	Anamosa	IA	IA	Shane Kies	Dave Reitseger	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Everett Williams	williamshardwood@aol.com	Owner	Anamosa	IA	IA	Shane Kies	Dave Reitseger	Signed
1264	2022-08-16 21:22	Anonymous (not verified)	50.82.84.19	Nogotta Trucking LLC	Limited Liability Company	16617 Wilden Dr, 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.	2022-08-16	Adam Dickinson	nogottatruckingllc@gmail.com	Clive	IA	United States	Gary Dickinson	Mike Martens	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Dickinson	nogottatruckingllc@gmail.com	Managing Member	Clive	IA	United States	Gary Dickinson	Mike Martens	Signed
1280	2022-08-22 15:48	Anonymous (not verified)	104.222.83.187	Cabinet Kulture LLC	Limited Liability Company	927 N. West St. Carroll, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Jordan Ellis	cabinetkulture@gmail.com	Carroll	IA	United States	Morgan Ellis	Ryan Winkelman	Signed	(1) The employer does not elect the employers’ liability coverage.	Cabinet Kulture LLC	cabinetkulture@gmail.com	Same person	Carroll	IA	United States	Morgan Ellis	Ryan Winkelman	Signed
1294	2022-09-04 18:09	Anonymous (not verified)	38.121.112.25	Cabinets and Closets by Design LLC	Limited Liability Company	18409 250th Street, Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-04	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	COUNCIL BLUFFS	IA	United States	Jim Sietsema	Jeff Deramcy	Signed	(1) The employer does not elect the employers’ liability coverage.	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	self	COUNCIL BLUFFS	IA	United States	TIMOTHY SLOBODNIK	TIMOTHY SLOBODNIK	Signed
1295	2022-09-05 20:39	Anonymous (not verified)	173.30.59.248	Guide LLC	Limited Liability Company	1655 Ashton Place, 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.	2022-09-05	Braydon Fisher	braydonfisher28@gmail.com	Dubuque	IA	United States	Conner Cole	Alec Kolander	Signed	(1) The employer does not elect the employers’ liability coverage.	Braydon Fisher	braydonfisher28@gmail.com	Owner	Dubuque	IA	United States	Conner Cole	Alex Kolander	Signed
1341	2022-10-23 14:31	Anonymous (not verified)	97.127.255.147	Traver Home Improvement	Limited Liability Company	14150 110 th Ave. Davenport, IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-24	Barry S Traver	traverhomeimprovement@gmail.com	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed	(1) The employer does not elect the employers’ liability coverage.	Barry S Traver	traverhomeimprovement@gmail.com	self	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed
1347	2022-10-26 14:42	Anonymous (not verified)	173.21.223.66	Mid American Roofing	Limited Liability Company	811 8th St Kalona IA 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-26	Josiah Hoyt	midamericanroofing@gmail.com	KALONA	IA	United States	Jensen Ropp	Randy Ropp	Signed	(1) The employer does not elect the employers’ liability coverage.	Josiah Hoyt	josiahhoyt@gmail.com	Owner	KALONA	IA	United States	Jensen Ropp	Randy Ropp	Signed
1349	2022-10-28 12:37	Anonymous (not verified)	173.26.153.59	spotlight drywall	Proprietorship	1001 7th st.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-01	paul woods	spotlight.2008@hotmail.com	Grundy Center	Ia	United States	thuy do	jaden do	Signed	(1) The employer does not elect the employers’ liability coverage.	thuy do	spotlight.2008@hotmail.com	bookeeper	Grundy Center	Ia	United States	thuy do	jaden do	Signed
1364	2022-11-09 09:57	Anonymous (not verified)	50.80.120.38	Egl Enterprises, Inc.	Proprietorship	314 2ND AVE NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-09	EUGENE G LARUE	egl.enterprises.inc@gmail.com	HAMPTON	IA	United States	stephanie hofer	aryel laRue	Signed	(1) The employer does not elect the employers’ liability coverage.	EUGENE G LARUE	egl.enterprises.inc@gmail.com	self	HAMPTON	IA	United States	stephanie hofer	aryel laRue	Signed
1370	2022-11-13 19:49	Anonymous (not verified)	174.213.144.30	Iowa’s Gutter Specialist	Limited Liability Company	1390 Lark Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-21	Dustin Halverson	dh42312695@gmail.com	Hampton	IA	United States	Patricia Reynolds	Heather Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Halverson	dh42312695@gmail.com	Owner	Hampton	IA	United States	Patricia Marie Reynolds	Heather Marie Halverson	Signed
1371	2022-11-14 10:55	Anonymous (not verified)	166.181.86.95	Dean Abramczak	Proprietorship	524 Nodaway Dr center Point Iowa 52213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-16	Dean Abramczak	gabramczak@gmail.com	Center Point	IA	United States	Brenda Oconner	Kenny McGraw	Signed	(1) The employer does not elect the employers’ liability coverage.	Dean Abramczak	gabramczak@gmail.com	I am the only employee I own the company	Center Point	IA	United States	Brenda Oconnner	Kenny McGraw	Signed
1373	2022-11-16 12:28	Anonymous (not verified)	173.22.187.22	MCDONALD'S LAWN & TREE SERVICES	Proprietorship	1130 N. 4 AVE. W. NEWTON IA 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-16	Roger McDonald	RABBITMCDONALD@HOTMAIL.COM	Newton	IA	United States	Patricia McMahon	Bryan McMahon	Signed	(1) The employer does not elect the employers’ liability coverage.	Roger McDonald	RABBITMCDONALD@HOTMAIL.COM	Self	Newton	IA	United States	Patricia McMahon	Bryan McMahon	Signed
1380	2022-11-26 07:41	Anonymous (not verified)	173.17.229.18	M&M Construction LLC	Limited Liability Company	32785 Homestead Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-23	Amparo Yamilet Menendez Gonzalez	menendez.amparo@yahoo.com	Granger	Dalles center	United States	Carla Diaz	Jesus Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerardo Alvarado	bariel578@gmail.com	Employee	Perry	IA	United States	Carla Diaz	Jesus lopez	Signed
1389	2022-12-11 12:36	Anonymous (not verified)	24.149.1.5	Project Fix It LLC	Limited Liability Company	1303 Washington Street Cedar Falls Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-12	Adam L Reiter	adam.reiter@projectfixit.net	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Project Fix It	adam.reiter@projectfixit.net	Owner	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed
1405	2023-01-04 11:56	Anonymous (not verified)	67.55.135.18	Duncan Home Services LLC	Limited Liability Company	2543 Cottage Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-04	Travis Duncan	projects@duncanhs.com	Waverly	IA	United States	Alethea Duncan	Kristine Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Duncan	projects@duncanhs.com	self	Waverly	IA	United States	Alethea Duncan	Kristine Fisher	Signed
1406	2023-01-04 11:58	Anonymous (not verified)	67.55.135.18	Duncan Home Services LLC	Limited Liability Company	2543 Cottage Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-04	Alethea Anne Duncan	projects@duncanhs.com	Waverly	IA	United States	Travis Duncan	Kristine Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Duncan	projects@duncanhs.com	spouse	Waverly	IA	United States	Travis Duncan	Kristine Fisher	Signed
1414	2023-01-07 22:14	Anonymous (not verified)	38.121.112.25	Cabinets and Closets by Design LLC	Proprietorship	18409 250th Street, 430	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-07	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	COUNCIL BLUFFS	IA	United States	Jim Sietsema	Jeff Deramcy	Signed	(1) The employer does not elect the employers’ liability coverage.	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	self	COUNCIL BLUFFS	IA	United States	TIMOTHY SLOBODNIK	TIMOTHY SLOBODNIK	Signed
1421	2023-01-13 09:43	Anonymous (not verified)	96.18.190.183	Home Base Inspection & Code Services, LLC	Limited Liability Company	3805 Ridge 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.	2023-01-13	Amanda Harper	amanda@hbicsvs.com	Sioux City	IA	United States	Terri Harper	Joy Brouilette	Signed	(1) The employer does not elect the employers’ liability coverage.	Amanda Harper	amanda@hbicsvs.com	self	Sioux City	IA	United States	Terri Harper	Joy Brouillette	Signed
1435	2023-01-31 14:33	Anonymous (not verified)	174.215.242.112	Premier builders	Proprietorship	1821 East Ridgeway	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-31	Edward Koch	etkdbq@aol.com	Waterloo	IA	United States	Glenda mclarty	Coen Koch	Signed	(1) The employer does not elect the employers’ liability coverage.	Edward Koch	etkdbq@aol.com	Owner	Waterloo	IA	United States	Glenda Mclarty	Coen Koch	Signed
1457	2023-02-15 18:06	Anonymous (not verified)	94.188.205.166	Chad Cowan	Limited Liability Company	2108 Locust St West Des Moines IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-15	Chad Stuart Cowan	chad@bigroofing515.com	West Des Moines	Polk	Iowa	Paul Mouw	Rob Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Cowan	rr2cw@yahoo.com	Same	West Des Moines	IA	United States	Paul Mouw	Rob Schultz	Signed
1462	2023-02-17 13:45	Anonymous (not verified)	94.188.207.227	Med Spa Institute of America, Dubuque LLC	Limited Liability Partnership	3337 Hillcrest Rd - Dubuque, 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.	2023-01-11	Kaylee Webb	jheims@english-insurance.com	Dubuque	Dubuque	United States	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	self	Dyersville	IA	United States	Joyce Heims	Derrick Parsons	Signed
1467	2023-02-17 16:14	Anonymous (not verified)	94.188.205.169	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	H & C Construction	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed
1486	2023-02-26 17:53	Anonymous (not verified)	94.188.205.177	TURNER LAWN CARE	Limited Liability Company	16493 185th Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-27	JEFF TURNER	jscturner2626@gmail.com	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed	(1) The employer does not elect the employers’ liability coverage.	SHARON RENEE TURNER	jscturner2626@gmail.com	wife	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed
1495	2023-03-06 09:57	Anonymous (not verified)	94.188.207.224	Midwest Indoor Air Quality, LLC	Limited Liability Company	701 NE Brook Haven Drive, Ankeny, IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	Tanner Evan Francisco	tanner.midwestindoorairquality@outlook.com	Ankeny	IA	United States	Sherry Reynolds	David Boyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Midwest Indoor Air Quality, LLC	tanner.midwestindoorairquality@outlook.com	Same	Ankeny	IA	United States	Sherry Reynolds	David Boyer	Signed
1496	2023-03-06 11:24	Anonymous (not verified)	94.188.207.227	Carrillo Drywall, LLC	Limited Liability Company	119 Marsh St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	Yesenia Carrillo	yesecarrillo84@gmail.com	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Hildman	kyleh@sinnottagency.com	Insurance Agent	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed
1508	2023-03-09 10:34	Anonymous (not verified)	94.188.205.176	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Charles Clarke	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed
1523	2023-03-18 13:15	Anonymous (not verified)	94.188.207.223	Aguilera’s Lawn Care LLC	Limited Liability Company	827 17th Street Southeast, Altoona, 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.	2023-03-18	Jose Aguilera	aguileramowing20@gmail.com	Altoona	IA	United States	Heather Aguilera	Heather Aguilera	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Aguilera	aguileramowing20@gmail.com	Self- owner	Altoona	IA	United States	Heather Aguilera	Heather Aguilera	Signed
1539	2023-03-28 16:50	Anonymous (not verified)	94.188.207.230	Sulzner Construction LLC	Limited Liability Company	210 N CHERRY ST, PO BOX 264	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-28	Aksel C Sulzner	akselsmoke@gmail.com	Mechanicsville	IA	United States	self	self	Signed	(1) The employer does not elect the employers’ liability coverage.	Aksel C Sulzner	akselsmoke@gmail.com	Self	Mechanicsville	IA	United States	self	self	Signed
1541	2023-03-29 11:21	Anonymous (not verified)	94.188.205.174	Juilfs Trucking	Proprietorship	709 S Geneva St., P.O. Box 252	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Terry Juilfs	sarah_burke7274@hotmail.com	Pomeroy	IA	United States	Lorie Gerdes	Kerstin Lyon	Signed	(1) The employer does not elect the employers’ liability coverage.	Terry Juilfs	sarah_burke7274@hotmail.com	Myself	Pomeroy	IA	United States	Lorie Gerdes	Kerstin Lyon	Signed
1543	2023-03-29 15:37	Anonymous (not verified)	94.188.207.225	Sulzner Construction LLC	Limited Liability Company	210 N CHERRY ST, PO BOX 264	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Aksel C Sulzner	akselsmoke@gmail.com	Mechanicsville	IA	United States	Toni Pollard	Phil Rouse	Signed	(1) The employer does not elect the employers’ liability coverage.	Aksel C Sulzner	akselsmoke@gmail.com	Self	Mechanicsville	IA	United States	Toni Pollard	Phil Rouse	Signed
1553	2023-04-04 14:52	Anonymous (not verified)	94.188.205.177	TOPSOIL OUTDOOR SERVICES	Limited Liability Company	4919 SCHUBERT ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-04	LIBAN	topsoiloutdoor@gmail.com	AMES	IA	United States	Liban Wetzberger	Liban Wertzberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Liban Wertzberger	topsoiloutdoor@gmail.com	Owner	AMES	IA	United States	Liban Wertzberger	Liban Wertzberger	Signed
1557	2023-04-05 20:42	Anonymous (not verified)	94.188.207.228	Nava lawn care and junk hauling	Limited Liability Company	220 2nd Street 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.	2023-04-05	Joan Nava Becerril	jnb.2499@gmail.com	West Des Moines	IA	United States	Aylin Silva Garcia	Arjan Silva	Signed	(1) The employer does not elect the employers’ liability coverage.	Joan Nava Becerril	info@navalawnandjunk.com	OWNER	West Des Moines	IA	United States	Aylin Silva Garcia	Arjan Silva	Signed
1571	2023-04-13 10:30	Anonymous (not verified)	94.188.205.177	Pierick Enterprise 2	Limited Liability Company	806 6oth Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-13	SAMUEL PIERICK	wirehairguids@gmail.com	Pleasantville	IA	United States	Kelly Wyckoff	Andy Wyckoff	Signed	(1) The employer does not elect the employers’ liability coverage.	SAMUEL PIERICK	wirehairguids@gmail.com	Member	Pleasantville	IA	United States	Kelly Wyckoff	Andy Wyckoff	Signed
1577	2023-04-17 09:58	Anonymous (not verified)	94.188.205.167	Four Leaf LLC	Limited Liability Company	11150 NE 72nd St Bondurant IA 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-17	Eric O'Shea	Fourleaf2021@gmail.com	Bondurant	IA	United States	Lucas Gray	Curt Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Michael O'Shea	Fourleaf2021@gmail.com	Owner	Bondurant	IA	United States	Lucas Gray	Curt Decker	Signed
1581	2023-04-18 14:04	Anonymous (not verified)	94.188.205.177	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1582	2023-04-18 14:04	Anonymous (not verified)	94.188.205.177	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1583	2023-04-18 14:04	Anonymous (not verified)	94.188.205.166	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1584	2023-04-18 14:04	Anonymous (not verified)	94.188.205.166	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1585	2023-04-18 14:04	Anonymous (not verified)	94.188.205.167	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1613	2023-04-27 13:57	Anonymous (not verified)	94.188.207.227	Jacob's Ladder Construction	Proprietorship	406 10th st 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.	2023-04-27	Jacob Willis	jwillis924@gmail.com	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob A Willis	jwillis924@gmail.com	Owner	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed
1637	2023-05-10 15:39	Anonymous (not verified)	94.188.207.230	Carly Roskop	Proprietorship	7706 Hampshire Ct NE Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-10	Carly Roskop	carlyroskop@gmail.com	Cedar Rapids	IA	United States	Dustin Roskop	Tracy Petrak	Signed	(1) The employer does not elect the employers’ liability coverage.	Carly Roskop	carlyroskop@gmail.com	Self	Cedar Rapids	IA	United States	Dustin Roskop	Tracy Petrak	Signed
1671	2023-06-01 11:17	Anonymous (not verified)	94.188.205.166	Edwin Kime	Proprietorship	2920 Windsor av sumner iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	edwin kime	edwinkime01@gmail.com	sumner	ia	United States	Lori Ann kime	Kiley Nicole kime	Signed	(1) The employer does not elect the employers’ liability coverage.	edwin kime	edwinkime01@gmail.com	Same	sumner	ia	United States	Lori Ann kime	Kiley nicolevkime	Signed
1681	2023-06-08 15:55	Anonymous (not verified)	94.188.207.223	Cross Roads Builders, LLC	Limited Liability Company	3103 21st Street Camanche, IA.52730	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-08	Mark Allan Cross	rcreek2016@gmail.com	Davenport	iowa	United States	Barb Deering	Mike Cross	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Cross	rcreek2016@gmail.com	Owner/President	Davenport	IA	United States	Barb Deering	Mike Cross	Signed
1684	2023-06-09 14:42	Anonymous (not verified)	94.188.207.223	Brandon Thomas	Proprietorship	1119 Curtiss Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-08	Brandon K Thomas	Brandon.thomas@countitalljoy.com.mx	Ames	IA	United States	Leah Churchill	George Trice	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon K Thomas	Brandon.thomas@countitalljoy.com.mx	Same person	Ames	IA	United States	Leah Churchill	George Trice	Signed
1697	2023-06-20 14:36	Anonymous (not verified)	94.188.207.225	Quick Logistics LLC	Limited Liability Company	3817 Orleans Avenue, Sioux City, IA 51106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-20	Tony J Moeller	quick_logistics@outlook.com	Sioux City	IA	United States	Jordan Sitzmann	Cody Stultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Tony J Moeller	quick_logistics@outlook.com	Owner	Sioux City	IA	United States	Jordan Sitzmann	Cody Stultz	Signed
1705	2023-06-23 16:01	Anonymous (not verified)	94.188.205.176	MV Carpentry LLC	Limited Liability Partnership	32724 U.S. 69 Huxley IA 50124	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-23	Carlos Moreno	Silencitopunk@gmail.com	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlos Moreno	silencitopunk@gmail.com	Husband	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed
1744	2023-07-13 13:52	Anonymous (not verified)	94.188.205.176	T-Rex Construction LLC	Limited Liability Company	1203 Bluegrass Circle Unit 4 Cedar Falls Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-12	Claudia Rodriguez De Nunez	t.rexbigbiz@gmail.com	CEDAR FALLS	IA	United States	Ana Chavez	Alicia Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Guillermo Nunez	claudia.rodriguez.213@gmail.com	Spouse	CEDAR FALLS	IA	United States	Alicia Garcia	Ana Chavez	Signed
1752	2023-07-17 13:21	Anonymous (not verified)	94.188.207.225	GPS Construction	Limited Liability Company	920 Wolf Creek Polk City, IA 50226	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-07-17	Gregory Schultz	gregpschultz@gmail.com	POLK CITY	IA	United States	Dillon Temple	Derek Temple	Signed	(1) The employer does not elect the employers’ liability coverage.	Gregory Schultz	gregpschultz@gmail.com	Owner	POLK CITY	IA	United States	Dillon Temple	Derek Temple	Signed
1762	2023-07-26 12:42	Anonymous (not verified)	94.188.207.230	Down Home Decor, Inc	Proprietorship	1021 2nd Ave SE Ste 200 - Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Vicki Knipper	jheims@english-insurance.com	Dyersville	IA	IA	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	self agent	Dyersville	IA	IA	Joyce Heims	Derrick Parsons	Signed
1763	2023-07-26 12:46	Anonymous (not verified)	94.188.207.224	Down Home Decor Inc	Proprietorship	1021 2nd Ave SE Ste 200 - Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Steve Knipper	jheims@english-insurance.com	Dyersville	Dubuque	IA	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	self agent	Dyersville	IA	IA	Joyce Heims	Derrick Parsons	Signed
1765	2023-07-27 14:27	Anonymous (not verified)	94.188.207.225	Midwest Systems	Proprietorship	2877 130th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-27	Matt Griswold	midwestsystems@live.com	Aurora	IA	United States	Creatleigh Griswold	Carslyn Griswold	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Griswold	midwestsystems@live.com	Owner	Aurora	IA	United States	Creatleigh Griswold	Carslyn Griswold	Signed
1776	2023-08-03 13:51	Anonymous (not verified)	94.188.207.224	Lucas Adam Peterson	Proprietorship	2833 SE 68th St 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.	2023-08-03	Lucas Adam Peterson	Luke.Peterson.mzub@gmail.com	Pleasant Hill	POLK	IOWA	Sarah Peterson	Samuel Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Lucas Adam Peterson	Luke.Peterson.mzub@gmail.com	Self	PLEASANT HILL	IA	United States	Sarah Peterson	Samuel Peterson	Signed
1784	2023-08-04 10:39	Anonymous (not verified)	94.188.205.175	Danny Davis	Limited Liability Company	2733 Raccoon Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-04	Danny R Davis	ddavis3243@yahoo.com	Des Moines	IA	United States	Michael Gatewood	Brad Wheeler	Signed	(1) The employer does not elect the employers’ liability coverage.	HD EXTERIORS LLC	ddavis3243@yahoo.com	Owner	Des Moines	IA	United States	Michael Gatewood	Brad Wheeler	Signed
1788	2023-08-07 18:32	Anonymous (not verified)	94.188.205.168	Johnson Custom Paint & Design LLC	Limited Liability Company	1414 N 9TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-07	Josh Johnson	johnsoncustompaint@hotmail.com	Fort Dodge	Iowa	United States	JACKLYN JOHNSON	Roger Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Johnson	johnsoncustompaint@hotmail.com	owner	Fort Dodge	IA	United States	JACKLYN JOHNSON	Roger Johnson	Signed
1810	2023-08-21 10:18	Anonymous (not verified)	94.188.207.224	Vicente McCain	Proprietorship	524 panama st Nashua	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-08-20	Jose V Mccain	Vic_mccain@yahoo.com	Nashua	IA	United States	Rafael McCain	Jessica McCain	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jose V Mccain	Vic_mccain@yahoo.com	Brother	Nashua	IA	United States	Rafael McCain	Jessica McCain	Signed
1812	2023-08-22 08:00	Anonymous (not verified)	94.188.207.230	mike bethards	Proprietorship	3484 vermont st new virginia ia 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-22	mike w bethards	mwbethards@yahoo.com	new virginia	ia	United States	christine bethards	alice lohan	Signed	(1) The employer does not elect the employers’ liability coverage.	mike bethards	mwbethards@yahoo.com	same	new virginia	ia	United States	christine bethards	alice lohan	Signed
1833	2023-09-08 13:39	Anonymous (not verified)	94.188.207.225	Superior painting & epoxy coatings llc	Limited Liability Company	4918 ne crestmoor ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-05	Anthony Negrete jr	superior.paint@hotmail.com	Ankeny	IA	United States	Stacey Marie stoecker	Anthony Negrete jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Negrete jr	superior.paint@hotmail.com	Spouse	Ankeny	IA	United States	Anthony Negrete jr	stacey marie Stoecker	Signed
1839	2023-09-12 11:22	Anonymous (not verified)	94.188.205.167	J.S. Reeves Consulting LLC	Limited Liability Company	1610 1st Ave, Perry, IA 50220	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-12	joni Sue Reeves	jonisreeves@att.net	Perry	IA	United States	Maggie Rhodes	Barb Butler	Signed	(1) The employer does not elect the employers’ liability coverage.	Joni Sue Reeves	jsreeves67@gmail.com	Same	Perry	IA	United States	Maggie Rhodes	Barb Butler	Signed
1853	2023-09-26 10:16	Anonymous (not verified)	94.188.205.177	Saketh Mahavadi	Limited Liability Company	294 s 83rd street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-26	Saisaketh	sakethmahavadi@gmail.com	West Des Moines	IA	United States	David Chan	Ahnaf Yeasin	Signed	(1) The employer does not elect the employers’ liability coverage.	David Chan	Davidchan8873@gmail.com	Business Partner	West Des Moines	IA	United States	Saketh Mahavadi	Ahnaf Yeasin	Signed
1866	2023-10-11 08:17	Anonymous (not verified)	94.188.205.177	Wilson's Window Tinting	Limited Liability Company	385 South Stewart Street North Liberty, Iowa 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-07	Wilson Paiva	wilsonswindowtinting@gmail.com	North Liberty	IA	United States	John W. Helscher	Jose Omar Paz	Signed	(1) The employer does not elect the employers’ liability coverage.	Wilson Paiva	wilsonswindowtinting@gmail.com	Owner	North Liberty	IA	United States	John Helscher	Jose Omar Paz	Signed
1873	2023-10-20 09:25	Anonymous (not verified)	94.188.207.228	GC Hauling LLC	Limited Liability Company	310 North 18th Street, Indianola, IA, 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-20	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	Signed	(1) The employer does not elect the employers’ liability coverage.	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	Same Person	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	Signed
1878	2023-10-26 09:06	Anonymous (not verified)	94.188.205.168	Jones Facility Maintenance	Limited Liability Company	3929 Council Street NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-25	Mason Jones	jonesmason546@gmail.com	Cedar Rapids	IA	United States	Lindsey Jones	Seth Wennermark	Signed	(1) The employer does not elect the employers’ liability coverage.	Mason Bradley Jones	jonesmason546@gmail.com	Owner	Cedar Rapids	IA	United States	Lindsey Jones	Seth Wennermark	Signed
1885	2023-10-29 08:05	Anonymous (not verified)	94.188.207.223	MB Radon Services	Limited Liability Company	13206 State Hwy 2, Lamoni, Iowa, 50140	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-29	Kyle Ramaeker	raymaker83@gmail.com	LAMONI	IA	United States	Adam Boge	Lance Webster	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Ramaeker	raymaker83@gmail.com	Owner/Operator	LAMONI	IA	United States	Adam Boge	Lance Webster	Signed
1890	2023-11-01 19:22	Anonymous (not verified)	94.188.207.228	JACK SCHADE	Proprietorship	911 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.	2023-11-01	jack allan schade	jackschade@yahoo.com	Plymouth	IA	IA	jack allan schade	jack allan schade	Signed	(1) The employer does not elect the employers’ liability coverage.	jack allan schade	jackschade@yahoo.com	self	Plymouth	IA	IA	jack allan schade	jack allan schade	Signed
1900	2023-11-09 23:24	Anonymous (not verified)	94.188.207.224	Daniel Blanco	Proprietorship	1403 2nd Ave S	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-09	Daniel Blanco	chindan77@yahoo.com	Fort Dodge	IA	United States	Vanessa Blanco	Jorge Blanco	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Fort Dodge	IA	United States	Elva Castañeda	Vanessa Blanco	Signed
1902	2023-11-10 08:45	Anonymous (not verified)	94.188.207.226	Huff Construction LLC	Limited Liability Company	1309 Business 30 Sw, Mount Vernon, IA 52314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Jason Huff	huff.jasonm@gmail.com	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Huff	huff.jasonm@gmail.com	Owner	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed
1913	2023-11-20 13:48	Anonymous (not verified)	94.188.205.167	KWF SALES INC	Proprietorship	216 WINDFLOWER LANE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-20	KRISTI A WOODLEY-FLANSBURG	Kwflansburg@gmail.com	SOLON	Iowa	Iowa	ZACH GRANT	TOM SIMPSON	Signed	(1) The employer does not elect the employers’ liability coverage.	KRISTI A WOODLEY-FLANSBURG	Kwflansburg@gmail.com	SELF	SOLON	IA	IA	ZACH GRANT	TOM SIMPSON	Signed
1927	2023-11-29 13:13	Anonymous (not verified)	94.188.207.228	Yaardman landscaping llc	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-29	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	Owner	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
1928	2023-11-29 21:48	Anonymous (not verified)	94.188.205.168	Iowa Evolution Constuction	Partnership	1203 Bluegrass Cir	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-01	Claudia Rodriguez	claudia.rodriguez.213@gmail.com	CEDAR FALLS	IA	United States	Guillermo Nunez	Blanca rodriguez	Signed	(1) The employer does not elect the employers’ liability coverage.	Claudia Rodriguez	claudia.rodriguez.213@gmail.com	Owner	CEDAR FALLS	IA	United States	Guillermo Nunez	Blanca Rodriguez	Signed
1929	2023-11-30 10:46	Anonymous (not verified)	94.188.207.225	White Masonry, Inc.	Proprietorship	15141 Bluff Trl., Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-30	Jeff White	whitemasonry1979@hotmail.com	Carlisle	IA	IA	Cathleen Marie White	Sam Jeffrey White	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Dean White	WHITEMASONRY1979@HOTMAIL.COM	Self	CARLISLE	ia	ia	Cathleen Marie White	Sam Jeffrey White	Signed
1938	2023-12-05 11:54	Anonymous (not verified)	94.188.207.225	Genius automotive	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-05	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar james	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	None	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
1960	2023-12-16 11:58	Anonymous (not verified)	94.188.207.227	Landeros Framing	Proprietorship	2418 E 37th Ct	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-16	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	owner	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed
1970	2023-12-29 10:01	Anonymous (not verified)	94.188.205.168	Beatrice Banura	Proprietorship	14511 Bentwood Dr, Urbandale IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-29	Beatrice Banura	banurabeatrice4@gmail.com	Urbandale	Dallas	IA	Priscilla Saina	Gideon Saina	Signed	(1) The employer does not elect the employers’ liability coverage.	Beatrice Banura	banurabeatrice4@gmail.com	Self employed	Urbandale	IA	IA	Priscilla Saina	Gideon Saina	Signed
1974	2024-01-04 13:12	Anonymous (not verified)	94.188.205.167	Cro Outdoor Services, LLC	Limited Liability Company	1616 NW 78TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-20	Bojan Djukic	Croodsia@gmail.com	Clive	Iowa	United States	Cezar Villalobos	Maria Villalobos	Signed	(1) The employer does not elect the employers’ liability coverage.	Evetee Villalobos	e.villalobos91@gmail.com	s/o	Clive	IA	United States	Maria Villalobos	Cezar Villalobos	Signed
1982	2024-01-11 12:29	Anonymous (not verified)	94.188.205.166	Grace Justine	Proprietorship	405 Northview Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-11	Grace Justine Wandera / Independent Contractor	justine.wandera@candeoiowa.org	Waukee	IA	IA	Grace Justine Wandera / Independent Contractor	Grace Justine Wandera / Independent Contractor	Signed	(1) The employer does not elect the employers’ liability coverage.	Grace Justine Wandera / Independent Contractor	justine.wandera@candeoiowa.org	own	Waukee	IA	IA	Grace Justine Wandera / Independent Contractor	Grace Justine Wandera / Independent Contractor	Signed
1990	2024-01-16 22:22	Anonymous (not verified)	94.188.205.168	DeltaPro Painting & Remodeling	Limited Liability Company	1115 Nolan Court North Liberty 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.	2024-01-16	Bayron Amador	bayronamador59@gmail.com	North Liberty	IA	Estados Unidos	Claudia Garmendia	Marlon Amador	Signed	(1) The employer does not elect the employers’ liability coverage.	Bayron Amador	bayronamador59@gmail.com	Owner/Employer	North Liberty	IA	Estados Unidos	Claudia Garmendia	Marlon Amador	Signed
2000	2024-01-26 10:05	Anonymous (not verified)	94.188.205.177	Nick Myers Construction	Proprietorship	4736 Candlewick Drive, 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.	2024-01-26	Nicholas Myers	myersnicholasj@gmail.com	Norwalk	Warren	Iowa	John Myers	Brenda Myers	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Myers	nickmyersconstruction@gmail.com	Owner	Norwalk	IA	IA	John Myers	Brenda Myers	Signed
2016	2024-02-01 09:20	Anonymous (not verified)	94.188.207.225	Imperium Outdoor Solutions	Proprietorship	114 W Clanton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	Austin Beener	abeener033@gmail.com	St Charles	IA	United States	Austin Beener	Austin Beener	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Beener	abeener033@gmail.com	Operator	St Charles	IA	United States	Austin Beener	Austin Beener	Signed
2022	2024-02-02 12:24	Anonymous (not verified)	94.188.205.175	Short's Lawn Care LLC.	Limited Liability Company	309 2ND ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-02	Mike Short	Shortslawns@gmail.com	REDFIELD	IA	United States	Michael Thomas Short	Michael Short	Signed	(1) The employer does not elect the employers’ liability coverage.	Mike Short	Shortslawns@gmail.com	Owner	REDFIELD	IA	United States	Michael Thomas Short	Michael Short	Signed
2052	2024-02-22 07:37	Anonymous (not verified)	94.188.207.229	Noahs Ark Flooring	Proprietorship	6212 se 2nd 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.	2024-02-22	Noah James Daggett	daggettnoah365@gmail.com	Des moines	Polk	United States	Malichi Cerrato	Austin tolson	Signed	(1) The employer does not elect the employers’ liability coverage.	Noah James Daggett	daggettnoah365@gmail.com	Self	Des moines	IA	United States	Malichi Cerrato	Austin tolson	Signed
2061	2024-02-28 14:16	Anonymous (not verified)	94.188.205.166	Cael Gulrud	Proprietorship	206 W Main St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-28	Cael Gulrud	gulrud8728@gmail.com	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed	(1) The employer does not elect the employers’ liability coverage.	Cael Gulrud	gulrud8728@gmail.com	Me	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed
2063	2024-02-29 10:12	Anonymous (not verified)	94.188.205.177	Geral Lee Pattison	Proprietorship	22127 Hwy 52	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-29	Geral Lee Pattison	pattisonglee@gmail.com	GARNAVILLO	IA	IA	Lee Zapf	Andrew Corllet	Signed	(1) The employer does not elect the employers’ liability coverage.	Geral Lee Pattison	pattisonglee@gmail.com	Self	GARNAVILLO	IA	IA	Lee Zapf	Andrew Corllet	Signed
2066	2024-02-29 15:27	Anonymous (not verified)	94.188.207.230	Julian Abey	Proprietorship	4405 NW Abilene Road, Ankeny IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-29	Julian Abey	Jabeyhpro@gmail.com	Ankeny	Polk	IA	Eric Ndifon	Peter Gara	Signed	(1) The employer does not elect the employers’ liability coverage.	Julian Abey	Jabeyhpro@gmail.com	Self	Ankeny	IA	IA	Eric Ndifon	Peter Gara	Signed
2070	2024-03-01 10:21	Anonymous (not verified)	94.188.205.167	J&W siding LLC	Limited Liability Company	302 West Lincoln 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.	2024-03-01	william t Belz	5.4tritonf150@gmail.com	Walcott	IA	IA	william t Belz	william t Belz	Signed	(1) The employer does not elect the employers’ liability coverage.	william t Belz	5.4tritonf150@gmail.com	owner	Walcott	IA	IA	william t Belz	william t Belz	Signed
2075	2024-03-05 22:32	Anonymous (not verified)	94.188.207.225	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley 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.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed
2083	2024-03-08 14:41	Anonymous (not verified)	94.188.205.169	Michael Dwayne Wahl Jr DBA Dents Etc	Proprietorship	3458 Highway 65/69, Carlisle, Iowa 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-08	Michael Dwayne Wahl Jr	darrin@fisherbodypaint.com	Carlisle	Polk	Iowa	Darrin Morrison	Anthony Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Darrin Morrison	Anthony Garcia	Signed
2084	2024-03-08 15:18	Anonymous (not verified)	94.188.207.230	Heidi Vincent	Proprietorship	2213 SW White Birch Dr, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	Heidi Vincent	jared.vincent@insurancestationinc.com	Ankeny	Polk	Iowa	Jared Vincent	Colton Horak	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Jared Vincent	Colton Horack	Signed
2085	2024-03-08 15:22	Anonymous (not verified)	94.188.207.227	Laura Cook	Proprietorship	2213 SW White Birch Dr, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	Laura Cook	jared.vincent@insurancestationinc.com	Ankeny	Polk	Iowa	Jared Vincent	Colton Horak	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Jared Vincent	Colton Horack	Signed
2086	2024-03-08 19:11	Anonymous (not verified)	94.188.207.223	Handyman & More	Limited Liability Company	1214 Lindwood Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-08	Dustin allen Bergman	dustinbergman86@gmail.com	Carter Lake	IA	United States	Reesa Edie	Douglas Scadin	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin allen Bergman	dustinbergman86@gmail.com	Owner of company	Carter Lake	IA	United States	Reesa Edie	Douglas Scadin	Signed
2091	2024-03-12 15:23	Anonymous (not verified)	94.188.205.166	Shelley onnen	Proprietorship	1319 West 2nd 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.	2024-03-12	Shelley L Onnen	Shelleyonnen47@gmail.com	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelley L Onnen	Shelleyonnen47@gmail.com	Self	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed
2108	2024-03-20 12:51	Anonymous (not verified)	94.188.207.230	Mc Storm Restortion Services	Limited Liability Company	1913 NE LITTLE BEAVER DR	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-20	Michael Cross	crossmichael1@hotmail.com	Grimes	IA	United States	Courtney Lesher	Chandler Steffy	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Cross	crossmichael1@hotmail.com	owner	Grimes	IA	United States	Courtney Lesher	Chandler Steffy	Signed
2111	2024-03-21 14:28	Anonymous (not verified)	94.188.205.168	James Watson	Limited Liability Company	4708 71st Street Urbandale, 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.	2024-03-24	James Edward watson	junior99@email.com	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Lantz	jason@lantzelite.com	Employer	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed
2147	2024-04-12 11:52	Anonymous (not verified)	94.188.205.166	Tri County Enterprise	Partnership	5527 Crane Lane NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-12	Ken McGraw	kenmcgraw1974@gmail.com	Center Point	IA	United States	bob nissen	Jenny Vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Shellsburg	IA	United States	bob Nissen	Jenny Vaske	Signed
2148	2024-04-15 11:15	Anonymous (not verified)	94.188.207.224	Derek Fetzer	Proprietorship	360 250th St, West Branch, IA 52358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-17	Dere W Fetzer	kellylanz1967@gmail.com	West Branch	IA	United States	Maribelle Lund	Carl Lund	Signed	(1) The employer does not elect the employers’ liability coverage.	Derek Fetzer	kellylanz1967@gmail.com	Self	West Branch	IA	United States	Maribelle Lund	Carl Lund	Signed
2149	2024-04-15 11:20	Anonymous (not verified)	94.188.207.224	Grady Yeggy	Proprietorship	211 3rd St. Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-11	Grady S Yeggy	kellylanz1967@gmail.com	Riverside	IA	United States	Amanda Yeggy	Leah Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Grady S Yeggy	kellylanz1967@gmail.com	Self	Riverside	IA	United States	Amanda Yeggy	Leah Yeggy	Signed

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