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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:
1366 2022-11-10 09:33 Anonymous (not verified) 172.58.87.232 Blackstone Handy Services, LLC Limited Liability Company 1807 B Avenue Northeast I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-10 jovan walton blackstonehandyservices@gmail.com Cedar Rapids IA United States Mekaylah K. Stevens Dominique T. Walton Signed (1) The employer does not elect the employers’ liability coverage. jovan walton blackstonehandyservices@gmail.com Self Cedar Rapids Linn United States Mekaylah K. Stevens Dominique T. Walron Signed
1243 2022-08-04 21:00 Anonymous (not verified) 173.24.221.228 Foreman's Tile Creations Proprietorship 1412 Franklin 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. 2022-08-04 Sole Proprietor fudog4man@gmail.com Center Point Linn IA Aaron Foreman Aaron Foreman Signed (1) The employer does not elect the employers’ liability coverage. Aaron Foreman fudog4man@gmail.com I am the Employer Center Point Linn IA Aaron Foreman Aaron Foreman Signed
1080 2022-04-29 08:59 Anonymous (not verified) 216.51.225.18 Lee's Haul It & Property Care Proprietorship 212 Village Dr #5, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-29 Tim Lee timclee160@gmail.com Tiffin Johnson Iowa Lee Krueger Aaron Oehring Signed (1) The employer does not elect the employers’ liability coverage. Lee's Haul It & Property Care leeshaulit@gmail.com Owner Tiffin Johnson Iowa Tim Lee Aaron Oehring Signed
324 2020-11-20 09:08 Anonymous (not verified) 71.39.227.238 County-Line Construction, LLC Limited Liability Company 314 NE 2nd St, Panora, IA 50216 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-20 John Steve Vogel thevogels@netins.net Panora Guthrie Iowa Steve Phillips Abbey Luellen Signed (1) The employer does not elect the employers’ liability coverage. John Steve Vogel thevogels@netins.net Owner Panora Guthrie Iowa Steve Phillips Abbey Luellen Signed
422 2021-03-05 13:53 Anonymous (not verified) 71.39.227.238 Steven Phillips Proprietorship 1107 Walnut 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. 2021-03-06 Steven Phillips stevep@phillipsassociatesins.net Linden Guthrie Iowa Abbey Luellen RoseMary Phillips Signed (1) The employer does not elect the employers’ liability coverage. Steven Phillips stevep@phillipsassociatesins.net Self Linden Guthrie Iowa RoseMary Phillips Abbey Luellen Signed
423 2021-03-05 13:55 Anonymous (not verified) 71.39.227.238 RoseMary Phillips Proprietorship 1107 Walnut 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. 2021-03-05 RoseMary Phillips stevep@phillipsassociatesins.net Linden Guthrie Iowa Steven Phillips Abbey Luellen Signed (1) The employer does not elect the employers’ liability coverage. RoseMary Phillips stevep@phillipsassociatesins.net Self Linden Guthrie Iowa Steve Phillips Abbey Luellen Signed
621 2021-08-27 16:11 Anonymous (not verified) 71.39.227.238 DOUG WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, DALLAS CENTER, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-27 DOUG WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. DOUG WEISS EWEISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
622 2021-08-27 16:12 Anonymous (not verified) 71.39.227.238 DOUG AND ELLEN WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, DALLAS CENTER, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-27 ELLEN WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. ELLEN WEISS EWISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
1483 2023-02-25 14:57 Anonymous (not verified) 94.188.205.168 Van Wyk Lawn Services Limited Liability Company 14486 S. 128th ave E. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Anthony Eugene Van Wyk vanwykturf@gmail.com Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed (1) The employer does not elect the employers’ liability coverage. Anthony Eugene Van Wyk vanwykturf@gmail.com Self/Owner Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed
698 2021-10-28 16:09 Anonymous (not verified) 71.228.88.54 Warren Nelson Proprietorship 2525 Nebraska Street, 106, Sioux City, Iowa 51104 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 Scott D. Nelson scottdnelson@hotmail.com Sioux City Woodbury Iowa Wallace E Sheets Abby McDermott Signed (1) The employer does not elect the employers’ liability coverage. Beth L Sheets w143bs@verizon.net Daughter Sarasota Manatee Florida Wallace E. Sheets Abby McDermott Signed
1691 2023-06-14 19:20 Anonymous (not verified) 94.188.205.174 Amazing Painting LLC Limited Liability Company 1301 Boyd Street, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Evan Michael Regenwether Evan@amazingpaintingia.com Des Moines Polk Iowa Austin Matthew Regenwether Abby Marie Regenwether Signed (1) The employer does not elect the employers’ liability coverage. Evan Michael Regenwether evan@amaingpaintingia.com Owner Des Moines Polk Iowa Austin Matthew Regenwether Abby Regenwether Signed
195 2020-06-29 08:55 Anonymous (not verified) 107.77.173.23 E.S.T. Construction LLC Limited Liability Company 2412 E 16th st Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-29 Eber Saul Torres estorres48@gmail.com Des Moines Polk Iowa Hailey Galdames Luna Abel Mejia Signed (1) The employer does not elect the employers’ liability coverage. Eber Saul Torres estorres48@gmail.com Self Des Moines Polk IOWA Hailey Galdames Luna Abel Mejia Signed
770 2021-11-22 18:17 Anonymous (not verified) 192.82.97.13 Paul Wire Proprietorship 1005 25th Street SW, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Paul Wire gizzmochee@gmail.com Spencer Clay IA Lori Wire Abigail Miles Signed (1) The employer does not elect the employers’ liability coverage. Paul Wire gizzmochee@gmail.com Self Spencer Clay IA Lori Wire Abigail Miles Signed
666 2021-10-07 08:12 Anonymous (not verified) 208.126.166.149 Toribio Construction LLC Limited Liability Company 107 W Maxson Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-07 Jose Toribio osorioabigail0224@gmail.com West Liberty Muscatine IA Anthony Johnson Abigail Osorio Signed (1) The employer does not elect the employers’ liability coverage. Jose Toribio osorioabigail0224@gmail.com Owner West Liberty Muscatine IA Anthony Johnson Abigail Osorio Signed
258 2020-09-15 13:14 Anonymous (not verified) 50.83.182.140 Moyer Painting Proprietorship 934 Norwood Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 jerome Moyer moyer_painting@live.com Norwalk IA United States Sally Moyer Adam Adams Signed (1) The employer does not elect the employers’ liability coverage. jerome b moyer moyer_painting@live.com Self norwalk IA United States sally moyer Adam Adams Signed
217 2020-07-27 14:56 Anonymous (not verified) 72.2.163.232 Calvin Kroger Proprietorship 48232 292nd St. Hudson, SD 57034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-27 Calvin Kroger calvinkroger@gmail.com Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed (1) The employer does not elect the employers’ liability coverage. Calvin Kroger calvinkroger@gmail.com proprietor Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed
624 2021-08-30 15:53 Anonymous (not verified) 174.253.66.113 Leaf Home Solutions LLC Limited Liability Company 1595 Georgetown Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-30 Chad York Cyork027@gmail.com Davenport Scott Iowa Chad York Adam Coleman Signed (1) The employer does not elect the employers’ liability coverage. Adam Coleman ARColeman@leafhome.com Recruiter Hudson Summit Ohio Chad York Adam Coleman Signed
1662 2023-05-25 12:52 Anonymous (not verified) 94.188.205.176 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1418 NW Applewood St. Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike Kaut Adam Lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
1663 2023-05-25 12:56 Anonymous (not verified) 94.188.205.167 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1417 NW Applewood St. Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike kaut Adam lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
590 2021-07-29 16:38 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Joshua Arthur Soppe choiceagservices@gmail.com Manchester Delaware Iowa Dustin Fessler Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Joshua Arthur Soppe choiceagservices@gmail.com Owner Manchester Delaware Iowa Dustin Fessler Adam Reth Signed
591 2021-07-29 16:42 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Dustin Fessler dustin@choiceagservices.com Manchester IA United States Josh Soppe Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Dustin Fessler dustin@choiceagservices.com Owner Manchester Delaware Iowa Josh Soppe Adam Reth Signed
785 2021-12-09 09:15 Anonymous (not verified) 174.198.75.71 Daniel Vega camacho Proprietorship 2415 river ,meadows drive Des Moines Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-09 Daniel Vega camacho dvega50265@gmail.com Des Moines Polk Iowa Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Daniel Vega camacho dvega50265@gmail.com Self Des Moines Polk Iowa Chad Smith Adam Smith Signed
1134 2022-05-31 09:08 Anonymous (not verified) 65.125.92.130 EAC Multi-Services, Inc, Proprietorship 6224 Forest Ave. Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-31 Alan E Enamordo enriqueecalowcare@gmail.com Des Moines Polk Iowa Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Alan E Enamordo enriqueecalowcare@gmail.com self Des Moines Polk IA Chad Smith Adam Smith Signed
1171 2022-06-24 09:40 Anonymous (not verified) 65.125.92.130 Vega's Pro Painting, LLC Limited Liability Company 2415 River Meadows Dr. Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-24 Daniel Vega Camacho dvega50265@gmail.com Des Moines Polk IA Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Daniel Vega Camacho dvega50265@gmail.com Self Des Moines Polk IA Chad Smith Adam Smith Signed
1912 2023-11-16 08:40 Anonymous (not verified) 94.188.205.175 JC LANDSCAPING & LAWN CARE Proprietorship 4940 E. SHERIDAN AVE DES MOINES, IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-16 CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed (1) The employer does not elect the employers’ liability coverage. CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM SELF DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed
571 2021-07-12 09:51 Anonymous (not verified) 67.55.237.31 Steve Vogel Proprietorship 314 NE 2ND ST. Panora, Iowa 50216-2020 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-12 Steve Vogel thevogels@netins.net PANORA Guthrie United States Diana Vogel Adam Vogel Signed (1) The employer does not elect the employers’ liability coverage. Steve Vogel thevogels@netins.net Self PANORA Guthrie Iowa Diana Vogel Adam Vogel Signed
1396 2022-12-19 18:35 Anonymous (not verified) 174.198.65.20 Flyover Productions LLC Limited Liability Company 300 S Clinton 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. 2022-12-19 Richard A Redfern richredfern3@gmail.com Iowa City IA United States Susan Redfern Aditi Reddy Signed (1) The employer does not elect the employers’ liability coverage. Richard Redfern richredfern3@gmail.com Owner of company Iowa City Iowa United States Susan Redfern Aditi Reddy Signed
542 2021-06-16 07:26 Anonymous (not verified) 173.23.202.34 Russell’s lawn & landscape Limited Liability Company 285 robins rd, Hiawatha unit C16 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-16 Johnoy Khalil Russell johnoyjrrussell@gmail.com Hiawatha Linn Iowa Adrian pink Rupert Ellis Signed (1) The employer does not elect the employers’ liability coverage. Johnoy Khalil russell johnoyjrrussell@gmail.com Owner Hiawatha Linn Iowa Rupert ellis Adrian pink Signed
220 2020-08-02 13:45 Anonymous (not verified) 99.203.112.113 R&G SEAMLESS GUTTERS Proprietorship 3244 Dubuque Ave, 3244 Dubuque Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-02 Ruben Munoz Haro munozharoruben@gmail.com Des Moines Polk Estados Unidos Gabriel Ramirez Adriana Ramirez Signed (1) The employer does not elect the employers’ liability coverage. Ruben Munoz- R&G SEAMLESS GUTTERS Munozharoruben@gmail.com owner 3244 Dubuque Ave Des Moines Iowa 50317 polk iowa Gabriel Ramirez Adriana Ramirez 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
378 2021-01-29 11:43 Anonymous (not verified) 50.82.21.136 GRAPHIX MASTERS Limited Liability Company 420 Hamilton St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-01-29 Klayton Karl Kirkpatrick klay@graphixmasters.us Ottumwa IA United States Brian Wilson Aimee Kirkpatrick Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Klayton Kirkpatrick klay@graphixmasters.us Same Ottumwa Iowa United States Brian Wilson Aimee Kirkpatrick Signed
1456 2023-02-15 13:12 Anonymous (not verified) 94.188.205.168 Bloodgood construction services Proprietorship 4422 happy trail prole ia 50229 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Alan Dean bloodgood alanbloodgood@gmail.com Prole Warren Ia Derek bloodgood Albert bloodgood Signed (1) The employer does not elect the employers’ liability coverage. Bloodgood construction services alanbloodgood@gmail.com Self Prole Warren Ia Derek bloodgood Albert bloodgood Signed
2050 2024-02-16 09:45 Anonymous (not verified) 94.188.207.224 Mario Construction Limited Liability Company 1755 Huntington Rd Waterloo IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-16 Mario Lainez brocalainez73@gmail.com Waterloo Black Hawk Iowa Karolina Saenz Alejandra Maradiaga Signed (1) The employer does not elect the employers’ liability coverage. Mario Lainez brocalainez73@gmail.com Self Waterloo Black Hawk Iowa Karolina Saenz Alejandra Maradiaga Signed
68 2020-02-19 12:00 Anonymous (not verified) 198.14.241.59 SIERRA ROOFING LLC Limited Liability Company 909 N ELM ST WEST LIBERTY IA 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-19 ABRAHAM GRANJENO SIERRA89@GMAIL.COM WEST LIBERTY MUSCATINE IOWA JOSE SALGADO ALEJANDRIA FRAUSTO Signed (1) The employer does not elect the employers’ liability coverage. ABRAHAM GANJENO SIERRA89@GMAIL.COM OWNER WEST LIBERTY MUSCATINE IOWA JOSE SALGADO ALEJANDRIA FRAUSTO Signed
1407 2023-01-04 13:26 Anonymous (not verified) 67.55.135.18 Duncan Customs LLC Limited Liability Company 8857 Union Cir. Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-04 Rory Eugene Duncan ddmusicsolutions@gmail.com Cedar Falls Black Hawk Iowa Travis Duncan Alethea Duncan Signed (1) The employer does not elect the employers’ liability coverage. Rory Duncan ddmusicsolutions@gmail.com self Cedar Falls Black Hawk Iowa Travis Duncan Alethea Duncan 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
763 2021-11-22 12:32 Anonymous (not verified) 63.229.189.35 Adam Dotson Tiling Proprietorship 324 E 14th Street, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Adam Dotson adamdotson1975@gmail.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Adam Dotson adamdotson1975@gmail.com Self Spencer Clay Iowa Abigail Miles Alex Miles Signed
765 2021-11-22 16:07 Anonymous (not verified) 63.229.189.35 Stahmer Construction Proprietorship 318 Jackson St N Harris IA 51345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Alan Stahmer abigail@rickmilesartisans.com Harris Osceola Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Alan Stahmer abigail@rickmilesartisans.com Self Harris Osceola Iowa Abigail Miles Alex Miles Signed
766 2021-11-22 16:19 Anonymous (not verified) 63.229.189.35 Tribal Tile, LLC Limited Liability Company 1402 Ithaca Ave, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Josh Loerzel joshloerzel@gmail.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Josh Loerzel joshloerzel@gmail.com Self SPIRIT LAKE Dickinson IA Abigail Miles Alex Miles Signed
767 2021-11-22 16:42 Anonymous (not verified) 63.229.189.35 Lakes Custom Bath Proprietorship 3721 Ithaca Avenue, Spirit Lake IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Rick Dykshoorn abigail@rickmilesartisans.com SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Rick Dykshoorn abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
768 2021-11-22 16:53 Anonymous (not verified) 63.229.189.35 Jeff Luchtel Painting Proprietorship PO Box 225, Milford, IA 51351-0225 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Luchtel jluchtel@gmail.com Milford Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Luchtel abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
769 2021-11-22 17:13 Anonymous (not verified) 63.229.189.35 Jeff Johnson Proprietorship 3114 Keokuk Ave, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Johnson juliejeff1994@yahoo.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Johnson abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
772 2021-11-23 10:13 Anonymous (not verified) 63.229.189.35 Hubbards Cupboards Proprietorship 713 2nd Ave SW, Spencer, IA 51301-5603 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-23 James Hubbard abigail@rickmilesartisans.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. James Hubbard abigail@rickmilesartisans.com Self Spencer Clay Iowa Abigail Miles Alex Miles Signed
800 2021-12-15 16:50 Anonymous (not verified) 63.229.189.35 CT Home Services Limited Liability Company 706 Jackson Avenue, Spirit lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-15 Mike Oolman mikecthome@gmail.com Spirit lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Mike Oolman mikecthome@gmail.com Self Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed
869 2022-01-28 15:28 Anonymous (not verified) 63.229.189.35 Jones Painting Proprietorship PO box 523, Okoboji, IA 51355 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-28 JD Jones abigail@rickmilesartisans.com Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. JD Jones abigail@rickmilesartisans.com Self Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed
870 2022-01-28 15:51 Anonymous (not verified) 63.229.189.35 Cory Anderson Proprietorship 2234 141st St, Fort Dodge, IA 50501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-28 Cory Anderson coryleeanderson@yahoo.com Fort Dodge Webster Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Cory Anderson abigail@rickmilesartisans.com Self Fort Dodge Webster Iowa Abigail Miles Alex Miles Signed
1126 2022-05-25 12:06 Anonymous (not verified) 63.229.189.35 Frame 2 Finish LLC Limited Liability Company 25620 164th St Spirit lake, IA51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-05 Chris Miller frame2finish3550@gmail.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Chris Miller frame2finish3550@gmail.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
1115 2022-05-17 19:36 Anonymous (not verified) 173.23.50.204 Delgado Electrical Services Limited Liability Company 1210 Creston Ave Des Moines, Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-17 Cesar Delgado delgado.electrical@gmail.com Des Moines Polk Iowa Mike Willet Alex Segovia Signed (1) The employer does not elect the employers’ liability coverage. Cesar Delgado cesar.delgado31@yahoo.com Owner Des Moines Polk Iowa Mike Willet Alex Segovia Signed
303 2020-10-31 13:11 Anonymous (not verified) 173.17.230.149 Absolute Construction Limited Liability Partnership 135 main street, Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 James Nelson jamesnelson1983@gmail.com Carlisle Warren Iowa Joe Simpson Alex Vanderbeek Signed (1) The employer does not elect the employers’ liability coverage. James Nelson jamesnelson1983@gmail.com self Carlisle Warren Iowa Joe Simpson Alex Vanderbeek Signed
549 2021-06-25 16:19 Anonymous (not verified) 165.225.57.46 Shaw Livestock, LLC Limited Liability Company 6871 275th Street, Moravia, IA 52571-8003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-06-25 Steven H. Shaw steve@shawlivestock.com Moravia Appanoose Iowa Scott Saveraid Alexa Sheeder Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Steven Shaw steve@shawlivestock.com Self Moravia Appanoose Iowa Scott Saveraid Alexa Sheeder Signed
550 2021-06-25 16:20 Anonymous (not verified) 165.225.61.18 Shaw Livestock, LLC Limited Liability Company 6871 275th Street, Moravia, IA 52571-8003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-06-25 Nathan Shaw nate@shawlivestock.com Moravia Appanoose Iowa Scott Saveraid Alexa Sheeder Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Nathan Shaw nate@shawlivestock.com Self Moravia Appanoose Iowa Scott Saveraid Alexa Sheeder Signed
2059 2024-02-27 11:44 Anonymous (not verified) 94.188.205.169 Dowdey Construction LLC Limited Liability Company 1010 19th Ave - Rock Valley, IA 51247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-27 Nicholas Allen Dowdey nddowdey@hotmail.com Rock Valley Sioux Iowa Deidre Dawn Dowdey Alexander C Koedam Signed (1) The employer does not elect the employers’ liability coverage. Nicholas Allen Dowdey nddowdey@hotmail.com Self Rock Valley Sioux Iowa Deidre Dawn Dowdey Alexander C Koedam Signed
2117 2024-03-27 10:38 Anonymous (not verified) 94.188.207.226 ALCON CONSTRUCTION LLC Limited Liability Company 2613 GINDY DR, BELLEVUE, NE 68147 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-27 VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ Signed (1) The employer does not elect the employers’ liability coverage. VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM SELF BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ Signed
852 2022-01-21 15:52 Anonymous (not verified) 75.162.3.62 Alternative Interventions, LLC Limited Liability Company 3116 Ingersoll, #4 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-21 Carla Olson altint3116@gmail.com West Des Moines Dallas United States Michelle Grandstaff Alexandra Killinger Signed (1) The employer does not elect the employers’ liability coverage. CARLA OLSON altint3116@gmail.com Owner DES MOINES Polk United States Michelle Grandstaff Alexandra Killinger Signed
1949 2023-12-11 15:20 Anonymous (not verified) 94.188.207.223 Allens construction services llc Limited Liability Company 509 Nw Scott St Ankeny, Iowa 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-11 Allen Cheville acsllc515@gmail.com Ankeny Polk IOWA Allen Cheville Alexis Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Allen Cheville acsllc515@gmail.com Self Ankeny Polk IOWA Allen Cheville Alexis Zimmerman Signed
1524 2023-03-20 09:00 Anonymous (not verified) 94.188.205.177 David Roman Proprietorship 8350 EP True Parkway, Apt 1101, West Des Moines, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-20 David Roman vida8147@gmail.com West Des Moines Dallas IA Dario Lucas Barrera Alfonso Montoya Signed (1) The employer does not elect the employers’ liability coverage. David Roman vida8147@gmail.com Self West Des Moines Dallas IA Dario Lucas Barrera Alfonso Montoya Signed
464 2021-04-07 22:15 Anonymous (not verified) 173.18.251.105 TEMPLEMAN LAWN CARE AND SNOW REMOVAL Proprietorship 1612 Lomas Circle I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-07 TIM LEE Templeman nancytempleman@gmail.com Atlantic IA United States TARA JESSEN ALFRED WEDE Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. CULLEN AND ASSOCIATES tammy@cullenins.com Insurance agent Atlantic Cass Iowa Tara Jessen Alfred Wede Signed
465 2021-04-07 22:24 Anonymous (not verified) 173.18.251.105 TEMPLEMAN LAWN CARE Proprietorship 1612 Lomas Cr. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 Tim Lee Templemn nancytempleman@gmail.com Atlantic Iowa United States Tara Jessen Alfred Wede Signed (1) The employer does not elect the employers’ liability coverage. Tim Lee Templeman nancytempleman@gmail.com self Atlantic Iowa Iowa Tara Jessen Alfred Wede 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
104 2020-03-26 19:00 Anonymous (not verified) 173.189.167.170 MCB CONSTRUCTION INC Limited Liability Company 3484 VERMONT ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-26 michael wade bethards mwbethards@yahoo.com NEW VIRGINIA IA IA noel isaac alice lohmann Signed (1) The employer does not elect the employers’ liability coverage. mike bethards mwbethards@yahoo.com owner New Virginia warren IA noel isaac alice lohmann Signed
282 2020-10-21 07:00 Anonymous (not verified) 98.16.114.26 Fine Cut Lawn Service, LLC Limited Liability Partnership 110 E Street, SW. P.O. Box 835 Melcher, IA. 50163 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-19 Eric E Benz eric@finecutwaterscapes.com Melcher Marion IA Angelia Warner Allen Smith Signed (1) The employer does not elect the employers’ liability coverage. Eric Eugene Benz eric@finecutlawn.com same person Melcher Marion IA Angela Warner Allen Smith Signed
463 2021-04-06 21:34 Anonymous (not verified) 173.23.145.187 LANTZ ELITE CARPENTRY & CONSTRUCTION INC Limited Liability Company 1980 NW 94th St, Ste C Clive, IA 50325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-01 Jose J. Castillo castillojosejonathan7@gmail.com Des Moines Polk IOWA PERLA LANDAVERDE ALMA J. GAYTAN Signed (1) The employer does not elect the employers’ liability coverage. JOSE J. CASTILLO CASTILLOJOSEJONATHAN7@GMAIL.COM self Des Moines Iowa IOWA PERLA LANDAVERDE ALMA J. GAYTAN Signed
1068 2022-04-25 06:07 Anonymous (not verified) 172.58.84.213 Alondra Canedo Orta Limited Liability Company 4100 Hubbell Ave Apt#80 Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-25 Alondra Canedo Orta alondracanedo34@gmail.com Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed (1) The employer does not elect the employers’ liability coverage. Alondra Canedo Orta alondracanedo34@gmail.com Subcontractor Installer Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed
1834 2023-09-08 15:04 Anonymous (not verified) 94.188.205.177 Ryan Tucker Proprietorship 19000 hwy 69 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-08 Ryan Tucker rtlltucker@yahoo.com Indianola Warren Iowa Brooke Prior Aly Brose Signed (1) The employer does not elect the employers’ liability coverage. Ryan Tucker rtlltucker@yahoo.com Officer Indianola Warren Iowa Brooke Prior Aly Brose Signed
1936 2023-12-04 10:22 Anonymous (not verified) 94.188.205.174 Turkey River Ag Sales LLC Limited Liability Company 614 Vernon Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-04 David Ahern davidahern@turkeyriverag.com Cresco IOWA IOWA Michelle Ahern Alyse Ahern Signed (1) The employer does not elect the employers’ liability coverage. Turkey River Ag Sales LLC davidahern@turkeyriverag.com Owner Cresco Howard Iowa Michelle Ahern Alyse Ahern Signed
1968 2023-12-28 14:57 Anonymous (not verified) 94.188.205.175 Rose Frimpong Proprietorship 2110 NW 31st St. Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-28 Rose Frimprong domena69@hotmail.com Ankeny Polk Iowa Amabilis Ngwa Chris Abonge Signed (1) The employer does not elect the employers’ liability coverage. Rose Frimpong domena69@hotmail.com Self-employed Ankeny Polk Iowa Chris Abonge Amabilis Ngwa Signed
1861 2023-10-05 10:14 Anonymous (not verified) 94.188.207.227 Charles von Maur Proprietorship 18325 Robbins Road Pleasant Valley IA 52767 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-05 Charles von Maur rlarsen@vonmaur.com Pleasant Valley Scott IA Robert L Larsen Amanda Bratthauer Signed (1) The employer does not elect the employers’ liability coverage. Robert L Larsen rlarsen@vonmaur.com Outside consultant east moline Rock Island IL Josh Barnes Amanda Bratthauer Signed
1375 2022-11-18 10:21 Anonymous (not verified) 166.181.87.119 Heff Built Construction LLC Limited Liability Company 1403 Kodiak Dr NW Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-18 Jacob Heffernen jheffernen@gmail.com Cedar Rapids Linn IA Kyle Reid Amanda Frese Signed (1) The employer does not elect the employers’ liability coverage. Jacob Heffernen jheffernen@gmail.com N/A Cedar Rapids Linn IA Kyle Reid Amanda Frese Signed
1376 2022-11-18 10:22 Anonymous (not verified) 166.181.87.119 Ashley Heffernen Proprietorship 4009 Majestic Ct NE Cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-18 Ashley Rae Heffernen ashley.heffernen@gmail.com Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rae Heffernen ashley.heffernen@gmail.com Self Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed
1923 2023-11-27 11:21 Anonymous (not verified) 94.188.207.230 Chilled LLC Limited Liability Company 236 Meadow Breeze Ln Center Point IA 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. 2023-11-27 Lindsy J Trotter Lindsy@chilledfreezermeals.com Center Point Linn Iowa Abbie Snakenberg Amanda Guttau Signed (1) The employer does not elect the employers’ liability coverage. Lindsy Trotter Lindsy@chilledfreezermeals.com Owner Center Point Linn Iowa Abbie Snakenberg Amanda Guttau Signed
123 2020-04-16 08:33 Anonymous (not verified) 159.242.36.129 Paul Brown Proprietorship 5 Cedar Ridge CT, Ventura, IA 50482-8992 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-16 Paul Brown cedars4@cltel.net Ventura Cerro Gordo IA Tom Stephany Amanda Korenberg Signed (1) The employer does not elect the employers’ liability coverage. Paul Brown cedars4@cltel.net self Ventura Cerro Gordo IA Tom Stephany Amanda Korenberg Signed
491 2021-04-20 15:57 Anonymous (not verified) 199.102.210.217 mjm,inc Proprietorship 32345 200th st dallas centert ia 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-20 john paul wewrner johnpwerner17@gmail.com osage michell ia carolyn lee werner amanda lee johnson Signed (1) The employer does not elect the employers’ liability coverage. johnwerner johnpwerner17@gmail.com friend osage mithell ia carolyn lee werner amanda lee johnson Signed
1119 2022-05-18 11:51 Anonymous (not verified) 104.201.75.222 Gentry Hardware inc. Partnership 308 5th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-18 Nathan Dwaine Gentry gentrynathan@hotmail.com Rockwellcity Calhoun Iowa Emily Bethann Gentry Amanda Margaret Albee Signed (1) The employer does not elect the employers’ liability coverage. Nathan Dwaine Gentry gentrynathan@hotmail.com Owner Rockwellcity Calhoun Iowa Emily Bethann Gentry Amanda Margaret Albee Signed
427 2021-03-10 11:52 Anonymous (not verified) 66.188.136.150 Ronald Tessen Proprietorship 493 Hill St. Green Lake, WI 54941 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-10 Ronald Tessen kschumacher@tricorinsurance.com Green Lake Green Lake WI Russell Masartis Amanda Seeberger Signed (1) The employer does not elect the employers’ liability coverage. Ronald Tessen kschumacher@tricorinsurance.com Same Green Lake Green Lake WI Russell Masartis Amanda Seeberger Signed
428 2021-03-10 12:38 Anonymous (not verified) 66.188.136.150 John Smith Proprietorship 2490 E Main St. Lot 41, Plainfield, IN 46168 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-10 John Smith kschumacher@tricorinsurance.com Plainfield Hendricks IN Russell Masartis Amanda Seeberger Signed (1) The employer does not elect the employers’ liability coverage. John Smith kschumacher@tricorinsurance.com Same Plainfield Hendricks IN Russell Masartis Amanda Seeberger Signed
458 2021-04-05 11:59 Anonymous (not verified) 66.188.136.150 Joseph Chance Proprietorship 815 Richards Dr. Shorewood, IL 60404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-29 Joseph Chance kschumacher@tricorinsurance.com Shorewood Will IL Russell Masartis Amanda Seeberger Signed (1) The employer does not elect the employers’ liability coverage. Joseph Chance kschumacher@tricorinsurance.com Same Shorewood Will IL Russell Masartis Amanda Seeberger Signed
19 2019-12-31 16:29 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd 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. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Amar Music amarmusic01@gmail.com Owner Urbandale IA United States Sefik Music Amara Crncevic Signed
20 2019-12-31 16:36 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd 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. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Omer Okic ultimate.exteriors@gmail.com Owner Des Moines Polk IA Sefik Music Amara Crncevic Signed
652 2021-09-22 21:52 Anonymous (not verified) 209.152.66.250 Robert Stutzman Limited Liability Company 33784 Hwy 22 Keota, IA 25548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-22 Robert L Stutzman bnbstutzman@gmail.com Keota Keokuk Iowa Jo Edgington Amber Gent Signed (1) The employer does not elect the employers’ liability coverage. Sandra K Stutzman iafarmgirl90@gmail.com Daughter Keota Keokuk Iowa Jo Edgington Amber Gent Signed
339 2020-12-15 15:23 Anonymous (not verified) 74.221.46.229 CORRECTIONVILLE GOLF CLUB INC Limited Liability Company 1300 HACKBERRY STREET CORRECTIONVILLE IA 51016 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-15 KATIE EDWARDS KEDWARDS@FNBCORRECTIONVILLE.COM CORRECTIONVILLE WOODBURY IA CANDACE JACOBSON AMBER HANSEN Signed (1) The employer does not elect the employers’ liability coverage. KIM MEBIUS KMEBIUS@FNBCORRECTIONVILLE.COM PRESIDENT CORRECTIONVILLE WOODBURY IA CANDACE JACOBSON AMBER HANSEN Signed
1059 2022-04-19 15:06 Anonymous (not verified) 64.186.23.83 CORRECTIONVILL GOLF CLUB, INC Limited Liability Company 1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-19 NICK HEATH dogboy3485@yahoo.com CORRECTIONVILLE WOODBURY IOWA CANDACE JACOBSON AMBER HANSEN Signed (1) The employer does not elect the employers’ liability coverage. KATIE EDWARDS kedwards@fnbcorrectionville.com SEC/TREASURER CORRECTIONVILLE WOODBURY IOWA CANDACE JACOBSON AMBER HANSEN Signed
1060 2022-04-19 15:08 Anonymous (not verified) 64.186.23.83 CORRECTIONVILLE GOLF CLUB, INC Limited Liability Company 1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-19 ADAM KELLY dslkraz@gmail.com CORRECTIONVILLE WOOD IWOA CANDACE AMBER HANSEN Signed (1) The employer does not elect the employers’ liability coverage. KATIE EDWARDS kedwards@fnbcorrectionville.com SEC/TREASURER CORRECTIONVILLE WOODBURY IOWA CANDACE JACOBSON AMBER HANSEN Signed
880 2022-02-01 14:05 Anonymous (not verified) 207.45.88.5 Known Labs LLC Limited Liability Partnership 8350 Ep True Pkwy, UNIT 1201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-01 Marcus Antonio Smith mark@knownlabs.net West Des Moines Dallas IA Dan Morgan III Amber Smith Signed (1) The employer does not elect the employers’ liability coverage. Marcus Antonio Smith mark@knownlabs.net Owner West Des Moines IA IA Daniel Morgan III Amber Smith Signed
178 2020-06-08 13:51 Anonymous (not verified) 173.21.16.200 Daniel Mullanack Limited Liability Company 1208 Franklin St. Buffalo, IA 52728 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. 2020-06-08 daniel mullanack mullanackbuilders@mediacombb.net buffalo scott iowa brandon brooks amy carlson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. linda mullanack mullanackbuilders@mediacombb.net office manager buffalo scott iowa brandon brooks amy carlson Signed
2078 2024-03-06 16:19 Anonymous (not verified) 94.188.207.228 Iowa's Gutter Specialist LLC Limited Liability Company 221 4th St SE Hampton Iowa 50441 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-06 Dustin Halverson dh42312695@gmail.com Hampton Iowa United States Levi Paine Amy Hayes Signed (1) The employer does not elect the employers’ liability coverage. Dustin Halverson dh42312695@gmail.com Owner Hampton Iowa United States Levi Paine Amy Hayes Signed
1249 2022-08-09 14:14 Anonymous (not verified) 166.181.82.131 Kelly Kellogg Proprietorship 1305 N 1st st apt 16 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-09 Kelly Kellogg Kkell0223@gmail.com Indianola Warren Iowa Kelly Kellogg Amy Kellogg Signed (1) The employer does not elect the employers’ liability coverage. Kelly's Flooring Kkell0223@gmail.com Myself 1305 N 1st st apt 16 Warren Iowa Kelly Kellogg Amy Kellogg Signed
1016 2022-03-29 14:26 Anonymous (not verified) 104.145.202.155 S.M.Trucking Proprietorship 3270 Hwy 69 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Steve Miller S.M.Trucking52@gmail.com 3270 Hwy 69 Forest City Hancock Ia Julie Miller Amy Picha Signed (1) The employer does not elect the employers’ liability coverage. Steve Miller S.M.Trucking52@gmail.com Owner 3270 Hwy 69 Forest City Hancock Ia Julie Miller Amy Picha Signed
1596 2023-04-24 15:48 Anonymous (not verified) 94.188.205.174 Loyal Transport INC Proprietorship 1987 Middle Calmar Road, Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-01 Lloyd Bjergum aryan1950@hotmail.com Decorah, IA Winneshiek Iowa Allen Monroe Amy Ryan Signed (1) The employer does not elect the employers’ liability coverage. Lloyd Bjergum aryan1950@hotmail.com Self Decorah, Winneshiek Iowa Allen Monroe Amy Ryan 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
614 2021-08-20 12:20 Anonymous (not verified) 172.58.235.242 Darren Qualls Proprietorship 1515 Dewitt St. Ellsworth. IA 50075 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 Darren Wade Qualls d.qualls@outlook.com Ellsworth Hamilton IA Jeannie Kathleen Qualls Andrea Littleton Signed (1) The employer does not elect the employers’ liability coverage. Darren Wade Qualls d.qualls@outlook.com Self/Proprietor Ellsworth IA IA Jeannie Kathleen Qualls Andrea Littleton Signed
931 2022-02-21 15:04 Anonymous (not verified) 69.18.14.11 Lawn's Plus Proprietorship 6082 Northwest Beaver Drive, Johnston, Iowa 50131, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-01 Javier Nieto jacobanderson55@yahoo.com Des Moines Polk Iowa Jacob Anderson Andrea Nieto Signed (1) The employer does not elect the employers’ liability coverage. Javier Nieto jacobanderson55@yahoo.com Self Des Moiens Polk Iowa Jacob Anderson Andrea Nieto Signed
1817 2023-08-24 12:29 Anonymous (not verified) 94.188.207.223 Global Roofing LLC Limited Liability Company 504 Heritage Rd Cedar Falls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-20 Jose Rafael Delgado Marin grjrd808504@outlook.com Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed (1) The employer does not elect the employers’ liability coverage. Jose Rafael Delgado grjrd808504@outlook.com member Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed
1818 2023-08-25 15:16 Anonymous (not verified) 94.188.207.224 Global Roofing LLC Limited Liability Company 504 Heritage Rd Cedar Falls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-20 Yenifer Yomara Hernandez Solis Grjrd808504@outlook.com Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed (1) The employer does not elect the employers’ liability coverage. Jose Rafael Delgado Marin Grjrd808504@outlook.com member Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed
204 2020-07-15 11:21 Anonymous (not verified) 63.152.54.222 Tim Duggan Limited Liability Company 1405 1st St. SW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-15 Timothy M Duggan tdc.inc30@gmail.com Cedar Rapids Iowa United States Joe Willis Andrew Anson Signed (1) The employer does not elect the employers’ liability coverage. Timothy M Duggan tdc.inc30@gmail.com President Cedar Rapids Iowa United States Joe Willis Andrew Anson Signed
1969 2023-12-28 15:46 Anonymous (not verified) 94.188.205.176 Beau Vander Sluis Proprietorship 3000 Seneca 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. 2023-12-28 Beau Vander Sluis beauvsluis@gmail.com Des Moines Polk United States Braden Banning Andrew Behanish Signed (1) The employer does not elect the employers’ liability coverage. Beau Vander Sluis beauvsluis@gmail.com Same Des Moines Polk United States Braden Banning Andrew Behanish 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
1098 2022-05-12 17:54 Anonymous (not verified) 199.66.15.123 Timothy W Robinson Proprietorship 302 N Kenwood blvd Indianola 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. 2022-05-12 Timothy William Robinson williamswork18@gmail.com Indianola Warren Iowa Sarah Anne Robinson Andrew Gilbert Barber Signed (1) The employer does not elect the employers’ liability coverage. Timothy William Robinson williamswork18@gmail.com Sole proprietor Indianola Warren Iowa Sarah Anne Robinson Andrew Gilbert Barber Signed
229 2020-08-11 14:42 Anonymous (not verified) 75.162.158.159 Tanner Bruellman Limited Liability Company 205 NE 25th ct grimes, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-11 Tanner George Bruellman bruellmantan_1@hotmail.com Grimes Poll Iowa Mary Kathleen Bruellman Andrew Bruellman Signed (1) The employer does not elect the employers’ liability coverage. Mary Kathleen Bruellman bruellmantan_1@hotmail.com Wife Grimes Polk Iowa Mary Kathleen Bruellman Andrew James Bruellman Signed
1466 2023-02-17 15:12 Anonymous (not verified) 94.188.207.230 BIG Roofing, LLC Limited Liability Company 5751 NE 22nd St. #304 Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Tyler Jeffrey Baugh tj@bigroofing515.com Lincoln Lancaster Nebraska Steven Bieghler Andrew John Kohles Signed (1) The employer does not elect the employers’ liability coverage. Steven Craig Bieghler steve@bigroofing515.com Owner Cumming Dallas Iowa Tyler Jeffrey Baugh Andrew John Kohles Signed
1733 2023-07-10 14:30 Anonymous (not verified) 94.188.205.177 Leaf home Proprietorship 1595 Georgetown Rd., Hudson, OH 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-10 Andrew Koske aokoz_23@outlook.com East Moline IL United States Andrew Koske Andrew Koske Signed (1) The employer does not elect the employers’ liability coverage. Andrew Koske aokoz_23@outlook.com None East Moline IL United States Andrew Koske Andrew Koske Signed
688 2021-10-25 10:56 Anonymous (not verified) 75.91.173.195 Ami Westcott Proprietorship 2672 F 52 Trail Parnell, IA 52325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-25 Ami Lynn Westcott ami.westcott@gmail.com Parmell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed (1) The employer does not elect the employers’ liability coverage. Ami Lynn Westcott ami.westcott@gmail.com self Parnell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed
2093 2024-03-13 15:53 Anonymous (not verified) 94.188.205.176 Tony Deutmeyer Limited Liability Company PO BOX 152 HIAWATHA IA 52233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-13 Anthony John Deutmeyer tonydeutmeyer@gmail.com Hiawatha Linn Iowa Lacey riley Andrew prochaska Signed (1) The employer does not elect the employers’ liability coverage. Anthony Deutmeyer tonydeutmeyer@gmail.com Self Hiawatha Linn Iowa Lacey riley Andrew prochaska Signed
936 2022-02-25 10:47 Anonymous (not verified) 173.215.112.17 Arganbright Home Construction LLC Limited Liability Company 2251 Soldier Trail, Panora, IA 50216 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 David E Arganbright davearganbright@netins.net Panora Guthrie IA Cindy J Carstens Andrew Randol Signed (1) The employer does not elect the employers’ liability coverage. Christine M Arganbright chrisbia@netins.net Member Panora Guthrie IA Cindy J Carstens Andrew Randol Signed
480 2021-04-14 15:58 Anonymous (not verified) 65.103.82.36 Home Cleaning Services Proprietorship 1448 w 13th St 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. 2020-01-01 Jolene Lyn Brown j@gmail.com davenport scott IA Jamie Swanson Andrew Swanson Signed (1) The employer does not elect the employers’ liability coverage. Jolene Brown j@gmail.com owner davenport Scott IA Jamie Swanson andrew Swanson Signed
2166 2024-04-20 13:38 Anonymous (not verified) 94.188.205.175 Cedar Valley Seamless, LLC Limited Liability Company 1184 215th St, Jesup, IA 50648 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-20 Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed (1) The employer does not elect the employers’ liability coverage. Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Owner/Operator Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed
2034 2024-02-07 11:58 Anonymous (not verified) 94.188.207.230 Bryce Abbott Proprietorship 114 West Linn Street, Lone Tree, IA 52755 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-31 Bryce David Abbott bryceabbott86@gmail.com Lone Tree Johnson United States Dixie Abbott Andy Abbott Signed (1) The employer does not elect the employers’ liability coverage. Bryce Abbott bryceabbott86@gmail.com Self Lonetree Johnson IA Dixie Abbott Andy Abbott Signed
1796 2023-08-13 13:35 Anonymous (not verified) 94.188.205.176 Mirsad Mulic Limited Liability Company 7094 Hickory 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. 2023-08-13 Mirsad Mulic finecarpentry30@icloud.com Urbandale Polk IA Peter Griffin Andy Dufre Signed (1) The employer does not elect the employers’ liability coverage. Fine Carpentry finecarpentry30@icloud.com Partner Urbandale Polk IA Griffin Peterson Andy Dufre Signed
1277 2022-08-22 08:57 Anonymous (not verified) 68.169.247.177 Andrew Betts Proprietorship 305 3rd ave sw cascade 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 Andrew Betts dbidrywallco@gmail.com Cascade Dubuque Iowa Jamie manternach Andy hall Signed (1) The employer does not elect the employers’ liability coverage. Andrew Betts dbidrywallco@gmail.com Owner Cascade Iowa United States Jamie manternach Andy hall Signed
1774 2023-08-03 08:40 Anonymous (not verified) 94.188.205.168 J P Trucking, Inc. Proprietorship 8768 White Tail Lane, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-03 Jamison Noel jptrucking.jamison@gmail.com Dubuque DBQ Iowa Lindsay Noel Andy Kemp Signed (1) The employer does not elect the employers’ liability coverage. Jamison Noel jptrucking.jamison@gmail.com Owner Dubuque Dubuque Iowa Lindsay Noel Andy Kemp Signed
583 2021-07-23 12:37 Anonymous (not verified) 206.72.45.27 S&L Finishers LLC Limited Liability Company 307 N 5th Street Mallard Ia 50562 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-23 Luke AKRIDGE akridgel@ncn.net Mallard Palo Alto United States Kennedy Origer Andy Wiita Signed (1) The employer does not elect the employers’ liability coverage. Luke AKRIDGE akridgel@ncn.net Owner MALLARD IA United States Kennedy Origer Andy Wiita 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
1849 2023-09-19 14:57 Anonymous (not verified) 94.188.207.228 Iowa painting solutions llc Limited Liability Company 2500 pleasant 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. 2023-09-19 Patricia Davalos iowapaintingsolutionsllc@gmail.com Des Moines Polk Iowa Javier Rascon Angel Perez Signed (1) The employer does not elect the employers’ liability coverage. Iowa painting solutions llc iowapaintingsolutionsllc@gmail.com Owner Des Moines Polk Iowa Javier Rascon Angel Perez Signed
381 2021-02-02 12:46 Anonymous (not verified) 167.142.150.21 T and A Transfer, LLC. Limited Liability Company 3330 340th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-02 Todd L Ahrenholtz todd.ahrenholtz123@gmail.com Manilla IA IA Angela Ahrenholtz Angela Ahrenholtz Signed (1) The employer does not elect the employers’ liability coverage. Todd L Ahrenholtz todd.ahrenholtz123@gmail.com owner Manilla Iowa Iowa Angela Ahrenholtz Angela Ahrenholtz Signed
1372 2022-11-14 20:36 Anonymous (not verified) 198.14.213.147 Accurate Grading, LLC Limited Liability Company 1417 290th St Macksburg, IA 50155 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-14 Dustin A McVay dustin0980@gmail.com Macksburg IA United States Dustin A McVay Angela D McVay Signed (1) The employer does not elect the employers’ liability coverage. Dustin A McVay dustin0980@gmail.com Owner Macksburg United States Iowa Dustin A McVay Angela D McVay Signed
892 2022-02-03 15:52 Anonymous (not verified) 204.155.61.217 JD DRYWALL Proprietorship 503 9th Street Kalona, Iowa 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. 2022-02-03 John Duwa johnduwa@outlook.com Kalona Washington Iowa Jeff Spenner Angela Stutzman Signed (1) The employer does not elect the employers’ liability coverage. JD Drywall - John Duwa johnduwa@outlook.com owner Kalona Washington Iowa Jeff Spenner Angela Stutzman Signed
2138 2024-04-05 12:30 Anonymous (not verified) 94.188.205.167 Joseph L Neighbors dba J L N Trucking Proprietorship 5466 18th Ave Mount Auburn IA 52313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-05 Joseph L Neighbors robynne@cmbrown.net Mount Auburn Benton Iowa Sarah Svehla Angela Vangennip Signed (1) The employer does not elect the employers’ liability coverage. Robynne Dawn Duvall robynne@cmbrown.net insurance agent Perryville Missouri Missouri Sarah Svehla Angela Vangennip Signed
1035 2022-04-05 12:03 Anonymous (not verified) 199.120.121.97 Bruce Peters Painting Proprietorship 53568 Rosewood Road, Walnut IA 51577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Bruce Peters bpeters1992@yahoo.com Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed (1) The employer does not elect the employers’ liability coverage. Bruce Peters bpeters1992@yahoo.com self Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed
943 2022-03-03 13:49 Anonymous (not verified) 192.95.125.191 B & R Enterprises LLC Limited Liability Company 2850 73rd St, Newhall, IA 52315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. 2022-02-17 Ronald Jarrett ashlyn@3riversins.net Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Ronald Jarrett brsirenguys@gmail.com Member of LLC Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed
944 2022-03-03 13:54 Anonymous (not verified) 192.95.125.191 B&R Enterprises LLC Limited Liability Company 2850 73rd St., Newhall, IA 52315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. 2022-02-17 Bradley Rick ashlyn@3riversins.net Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Ronald Jarrett brsirenguys@gmail.com LLC Member Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed
1673 2023-06-02 09:30 Anonymous (not verified) 94.188.207.228 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Alyce Lynch kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1674 2023-06-02 09:34 Anonymous (not verified) 94.188.207.229 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Kyle Lynch kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1675 2023-06-02 09:37 Anonymous (not verified) 94.188.207.228 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Kevin Kacena kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1676 2023-06-02 09:41 Anonymous (not verified) 94.188.207.229 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Debra Kacena kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owners - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
130 2020-04-27 10:36 Anonymous (not verified) 66.188.136.150 David Roberts Proprietorship 2600 Butterfield, PO Box 3251 Dubuque, IA 52004 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 David Roberts buman6578@gmail.com Dubuque Dubuque IA Russell Masartis Angie Olds Signed (1) The employer does not elect the employers’ liability coverage. David Roberts kschumacher@tricorinsurance.com Owner Operator is Employer Dubuque Dubuque IA Russell Masartis Angie Olds Signed
263 2020-09-21 09:49 Anonymous (not verified) 66.188.136.150 Scott Kunz Proprietorship 114 10th Ave. 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. 2020-09-15 Scott Kunz kschumacher@tricorinsurance.com Camanche Clinton IA Russell Masartis Angie Olds Signed (1) The employer does not elect the employers’ liability coverage. Scott Kunz kschumacher@tricorinsurance.com Same Camanche Clinton IA Russell Masartis Angie Olds Signed
186 2020-06-15 08:03 Anonymous (not verified) 66.188.136.150 Candace Dingler Proprietorship 280 Trimble Station Road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-10 Candace Dingler kschumacher@tricorinsurance.com Hogansville Troup GA Russell Masartis Angie Ords Signed (1) The employer does not elect the employers’ liability coverage. Candace Dingler kschumacher@tricorinsurance.com Same Hogansville Troup GA Russell Masartis Angie Ords Signed
781 2021-12-08 08:41 Anonymous (not verified) 172.58.87.49 Diggins Installations Proprietorship 1619 48th st Des moines ia 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-06 Danny Allan Diggins ddigdan@gmail.com Des Moines Polk 1619 48th st Nancy Davis Angie Pilcher Signed (1) The employer does not elect the employers’ liability coverage. Danny Diggins ddigdan@gmail.com Self Des moines Polk Ia Nancy Davis Angie pilcher Signed
1694 2023-06-16 14:37 Anonymous (not verified) 94.188.205.176 Leaf Home Solutions LLC Partnership 3060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-16 Caleb Brincks chbrincks@gmail.com 628 NE 56th St Ankeny IA, 50021 Polk County Iowa Melissa Brincks Anisha Moten Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. AFTON INC chbrincks@gmail.com Owner Ankeny Polk Iowa Melissa Brincks Anisha Moten Signed
27 2020-01-06 09:17 Anonymous (not verified) 24.149.10.119 Miss Wonderful LLC Limited Liability Company 216 Main St Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 Ann Eastman misswonderful216@gmail.com Cedar Falls Black Hawk IA Rachel Lee Ann Remmert Signed (1) The employer does not elect the employers’ liability coverage. Ann Eastman misswonderful216@gmail.com Owner Cedar Falls Black Hawk IA Rachel Lee Ann Remmert Signed
1650 2023-05-16 12:06 Anonymous (not verified) 94.188.207.225 R & J Transport Proprietorship 85152 US HWY 81 PIERCE NE 68767 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-16 Ray Tom Clausen III jamieleabeutler2013@gmail.com Pierce NE United States Jamie Clausen Ann Siebrandt Signed (1) The employer does not elect the employers’ liability coverage. Ray T Clausen III jamieleabeutler2013@gmail.com Owner Pierce Pierce Ne Jamie Clausen Ann Siebrandt Signed
946 2022-03-04 10:43 Anonymous (not verified) 173.26.213.159 InTuition Painting & Design Proprietorship 2244 East 46th Place Davenport Iowa, 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-04 Brian J Bourke brianbourke@mediacombb.net Davenport Scott IA Anna E. Bourke Nicole K. Bourke Signed (1) The employer does not elect the employers’ liability coverage. Brian Bourke intuitionpainting@mediacombb.net Self Davenport Iowa Scott Iowa Nicole K. Bourkeq Anna E. Bourke Signed
1536 2023-03-27 10:47 Anonymous (not verified) 94.188.205.174 Cecile C Knipp Limited Liability Company 1418 Oakcrest Dr., Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-27 Cecile C Knipp ceilknipp@gmail.com Waterloo Black Hawk Iowa Monica Robbins Anne Betts Signed (1) The employer does not elect the employers’ liability coverage. Cecile C Knipp christinaknipp@aol.com Self Waterloo Black Hawk Iowa Monica Robbins Anne Betts Signed
1716 2023-06-29 09:19 Anonymous (not verified) 94.188.205.169 Christine wanjiru chege Limited Liability Company 43994 w cowpath rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-29 Christine Chege christine@acuitystaffingagency.com Maricopa Pinal AZ Daniel Mwangi Anne Chege Signed (1) The employer does not elect the employers’ liability coverage. Christine chege christine@acuitystaffingagency.com Owner Maricopa Pinal AZ Daniel Mwangi Anne Chege Signed
1554 2023-04-04 16:30 Anonymous (not verified) 94.188.205.176 House of Bean Studios Limited Liability Company 2066 170th Street, Guthrie Center, IA 50115 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Nicole Jazzmin Bean nicolebean.studios@gmail.com Guthrie Center Guthrie Iowa Daniel Bean Anthony Durst Signed (1) The employer does not elect the employers’ liability coverage. Nicole Jazzmin Bean houseofbeanstudios@gmail.com Self (Sole-proprietor LLC) Guthrie Center Guthrie Iowa Daniel Bean Anthony Durst 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
250 2020-09-01 12:08 Anonymous (not verified) 207.191.193.167 Jairo Varela Roofing Proprietorship 1681 Tofting Ave, Iowa City, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Jairo Servellon Varela olvinlanza06@gmail.com Iowa City Johnson IA Jessica Lopez Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Jairo Varela olvinlanza06@gmail.com Same Iowa City Johnson IA Jessica Lopez Anthony Johnson Signed
257 2020-09-14 16:15 Anonymous (not verified) 66.129.217.166 Lisseth Carolina Salas Melendez Proprietorship 3107 M & W Crl Muscatine, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Lisseth Carolina Salas Melendez chonrosales88@gmail.com Muscatine Louisa IA Rafael Crespo Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Lisseth Carolina Salas Melendez chonrosales88@gmail.com Same Muscatine Louisa IA Rafael Crespo Anthony Johnson Signed
346 2020-12-31 10:39 Anonymous (not verified) 66.129.217.166 GIL Construction, LLC Limited Liability Company 3107 M & W Crl, Muscatine, IA 52761 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-20 Lisseth Melendez Gil chonrosales88@gmail.com Muscatine Iowa United States Donis Medina Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Lisseth Melendez Gil chonrosales88@gmail.com Owner Muscatine Iowa United States Donis Medina Anthony Johnson Signed
384 2021-02-03 20:36 Anonymous (not verified) 66.129.217.166 GIL Construction, LLC Limited Liability Company 3107 M & W Crl I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Lisseth Melendez Gil tonypauljohnson@yahoo.com Muscatine Iowa United States Rafael Medina Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Lisseth Melendez Gil tonypauljohnson@yahoo.com Owner North Liberty IA United States Rafael Medina Anthony Johnson Signed
1925 2023-11-28 09:44 Anonymous (not verified) 94.188.207.224 Pietro Solutions Limited Liability Company 719 11th 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. 2023-11-28 Ronaldo Di Pietro girodp@gmail.com Rock Island Rock Island IL Rita de Cássia Gallo Antonio Carlos Gallo Signed (1) The employer does not elect the employers’ liability coverage. Ronaldo Di Pietro girodp@gmail.com Self Rock Island Rock Island IL Rita de Cássia Gallo Antonio Carlos Gallo Signed
756 2021-11-19 14:05 Anonymous (not verified) 65.144.174.26 Jaime Hernandez Lopez Proprietorship 223 N 9th Ave W, Newton, Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 Jaime Hernandez Lopez jaimehernandezlopez81@yahoo.com Newton Jasper Iowa Megan Ackerly Antonio Lopez Signed (1) The employer does not elect the employers’ liability coverage. Jaime Hernandez Lopez jaimehernandezlopez81@yahoo.com Self Newton Jasper Iowa Megan Ackerly Antonio Lopez Signed
1132 2022-05-28 12:01 Anonymous (not verified) 166.181.81.175 Kamp Trucking LLC Limited Liability Company 3411 doris 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. 2022-05-28 Joseph Michael Kamp boss4z9@yahoo.com waterloo Iowa United States Glenn Harrison Bearbower April Ann Bearbower Signed (1) The employer does not elect the employers’ liability coverage. Joseph Michael Kamp boss4z9@yahoo.com same person. I am an owner operator waterloo Iowa United States Glenn Harrison Bearbower April Ann Bearbower Signed
1867 2023-10-16 12:34 Anonymous (not verified) 94.188.205.176 North Bay Dock Service Proprietorship PO Box 374, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-16 Donald L. Johnson, Jr. djtjaj@outlook.com Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed (1) The employer does not elect the employers’ liability coverage. Teresa Johnson djtjaj@outlook.com bookkeeper Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed
1868 2023-10-16 12:36 Anonymous (not verified) 94.188.205.177 North Bay Dock Service, LLC Limited Liability Company PO Box 374, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-16 Teresa A. JOhnson NBDSLLC@gmail.com Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed (1) The employer does not elect the employers’ liability coverage. Teresa Johnson NBDSLLC@gmail.com Manager Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed
828 2022-01-11 10:34 Anonymous (not verified) 74.215.151.63 Marr Arnold Planning Limited Liability Company 1328 California Ave. Ames Iowa 50014 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-11 Sarah Arnold sarahkarnold@gmail.com Cincinnati Hamilton Ohio April Humphreys Amy Burns Signed (1) The employer does not elect the employers’ liability coverage. Sarah Arnold sarah@marrarnoldplanning.com Self Cincinnati Hamilton Ohio Amy Burns April Humphreys Signed
1552 2023-04-03 13:58 Anonymous (not verified) 94.188.205.168 F&I Drywall Llc Limited Liability Company 509 Arlington 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. 2023-04-03 Fernando Garcia Fgarcia1989.fg@gmail.com Marshalltown Marshall Iowa Gabriela Garcia Araceli Tafolla Signed (1) The employer does not elect the employers’ liability coverage. Fernando Garcia Fgarcia1989.fg@gmail.com Self Marshalltown Marshall Iowa Gabriela Garcia Araceli Tafolla Signed
2099 2024-03-15 18:50 Anonymous (not verified) 94.188.205.174 OMG Bros, LLC Limited Liability Partnership 404 Ivanhoe Rd, Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-03-15 Marco Antonio Gaytan marcogaytan77@gmail.com Waterloo Black Hawk Iowa Kaden Lyle Arayely Vazquez Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Tristan Anthony Siebrands omgservices@omgbros.org Partner Waterloo Black Hawk Iowa Kaden Lyle Arayely Vazquez Signed
1075 2022-04-28 07:53 Anonymous (not verified) 172.58.160.241 E & J Roofing LLC Limited Liability Company 5008 SE 5th Street 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. 2022-04-28 E & J Roofing LLC janeylli2006@hotmail.com Des Moines United States Iowa Javier Solís Saldaña Arhely S. Saldaña Signed (1) The employer does not elect the employers’ liability coverage. E & J Roofing LLC janeylli2006@hotmail.com Owner Des Moines Polk Iowa Javier Solís Saldaña Arhely S. Saldaña 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
1802 2023-08-15 15:23 Anonymous (not verified) 94.188.205.174 NORTH STARS, LLC Limited Liability Company 4374 STATE ST STE 2 BETTENDORF, IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-15 JOSE A DURAN MORALES northstarsllcmn@gmail.com BETTENDORF USA IOWA ARMANDO DURAN LILIANA SANCHEZ Signed (1) The employer does not elect the employers’ liability coverage. NORTH STARS, LLC northstarsllcmn@gmail.com BUSINESS OWNER BETTENDORF USA IOWA LILIANA SANCHEZ ARMANDO DURAN Signed
1998 2024-01-25 16:18 Anonymous (not verified) 94.188.205.168 Faith and Trust Soulutions LLC Limited Liability Company 139 37th Street NE Suite # 2 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-25 Marie Moore faithandtrustsoulutionsllc@gmail.com Cedar Rapids Iowa United States Arthur Barbine Arthur Barbine Signed (1) The employer does not elect the employers’ liability coverage. Arthur Barbine faithandtrustsoulutionsllc@gmail.com Friend Cedar Rapids Iowa United States Arthur Barbine Arthur Barbine 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
959 2022-03-09 10:30 Anonymous (not verified) 207.199.231.172 Steve Shepherd Proprietorship 332 N Walnut St Fremont, IA 52561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Steve Shepherd sheps2s69@gmail.com Fremont Mahaska Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Steve Shepherd sheps2s69@gmail.com Self Fremont Mahaska Iowa James Anderson Ashley Bryan Signed
961 2022-03-09 15:06 Anonymous (not verified) 207.199.231.172 Scott Ullrick Proprietorship 601 Grant St Beacon, IA 52534 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Scott Ullrick scottullrick@msn.com Beacon Mahaska IA James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Scott Ullrick scottullrick@msn.com Self Beacon Mahaska Iowa James Anderson Ashley Bryan Signed
962 2022-03-09 16:45 Anonymous (not verified) 207.199.231.172 Thomas Whitehead Proprietorship 1602 Green St Oskaloosa, IA 52577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Thomas Whitehead roctomjj@mahaska.org Oskaloosa Mahaska Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Thomas Whitehead roctomjj@mahaska.org Self Oskaloosa Mahaska Iowa James Anderson Ashley Bryan Signed
980 2022-03-16 09:38 Anonymous (not verified) 207.199.231.172 Sean Wursta Proprietorship 401 Strawberry St Eddyville, IA 52553 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-16 Sean Wurstra 5wurstas@gmail.com Eddyville Mahaska Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Self 5wurstas@gmail.com self Mahaska Eddyville Iowa James Anderson Ashley Bryan Signed
1011 2022-03-28 10:25 Anonymous (not verified) 207.199.231.172 Brian Carmer Proprietorship 133 S Iowa Ave, Ottumwa, IA 52501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Brian Carmer b_carmer@yahoo.com Ottumwa Wapello Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Brian Carmer B_Carmer@yahoo.com Self Ottumwa Wapello Iowa James Anderson Ashley Bryan Signed
1368 2022-11-11 11:58 Anonymous (not verified) 173.29.231.17 Marcelino Gutierrez Proprietorship 1705 Des Moines Street, Des Moines, Iowa 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-11 Marcelino Gutierrez lifestylefloors20@gmail.com Des Moines Polk Iowa Jerry Downing Ashley Temple Signed (1) The employer does not elect the employers’ liability coverage. Marcelino Gutierrez Lifestylefloors20@gmail.com owner Des Moines Polk Iowa Jerry Downing Ashley Downing Signed
1973 2024-01-02 17:05 Anonymous (not verified) 94.188.207.227 Diego Puente Proprietorship 1420 north st, apt#3 Perry 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. 2024-01-02 Diego Puente Martinez diegopuente0655@gmail.com Perry Dallas Iowa Jason Van Dyke Ashley Heffernen Signed (1) The employer does not elect the employers’ liability coverage. Jason Van Dyke jvandyke@thermalshop.com worker Cedar Rapids Iowa United States Jason Van Dyke Ashley Heffernen Signed
597 2021-08-05 13:38 Anonymous (not verified) 204.155.61.217 Haag Consulting LLC Limited Liability Company 8602 E Kael Circle, Mesa, AZ 85207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-05 Justin Haag haag.justin1@gmail.com Mesa unknown AZ DocuSign Ashley Kraft Signed (1) The employer does not elect the employers’ liability coverage. Justin Haag haag.justin1@gmail.com Owner Mesa unknown AZ DocuSign Ashley Kraft Signed
241 2020-08-23 16:10 Anonymous (not verified) 67.45.96.12 Wellik & Sons, LLC Limited Liability Company 1770 HWY 18, Garner, IA 50438 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-23 Jason Yon Juenger j420money@yahoo.com Garner Hancock Iowa Joshua P Wellik Ashley S Wellik Signed (1) The employer does not elect the employers’ liability coverage. Joshua Paul Wellik wellikandsons@gmail.com subcontractor Garner Hancock Iowa Joshua Paul Wellik Ashley S Wellik Signed
452 2021-03-26 07:30 Anonymous (not verified) 173.31.109.49 Rogers Concrete Construction Partnership 22802 County Rd E34 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-26 Alexander Olah aolah43@gmail.com Cedar Rapids Linn Iowa Robin Marie Kane Augies Rodrigez Signed (1) The employer does not elect the employers’ liability coverage. Kevin Johnson kevinjohnson@libertymutual.com Insurance Agent Appleton Outagamie Wisconsin Robin Marie Kane Augie Rodrigez Signed
451 2021-03-25 17:00 Anonymous (not verified) 166.181.80.120 Rogers conc,. const, Partnership 220804 CO, RD, ANAMOSA IA, 52205 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-25 Alex olah aolah43@gmail.com Cedar Rapids Linn Iowa Robin marie kane Augie rodreguez Signed (1) The employer does not elect the employers’ liability coverage. Kevin johnson kevinecollins@libertymutual.com Ins , Agent Appleton Dane Wisconsin Robin marie kane Augie Rodriguez 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
1821 2023-08-29 10:11 Anonymous (not verified) 94.188.205.169 Des Moines Smart Solutions LLC Limited Liability Company 1329 56th St., Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-29 Denzel Colocho alejandro_colocho@yahoo.com Des Moines Polk Iowa Steve Webb Austin Kelderman Signed (1) The employer does not elect the employers’ liability coverage. Des Moines Smart Solutions LLC alejandro_colocho@yahoo.com Owner Des Moines Polk Iowa Steve Webb Austin Kelderman Signed
927 2022-02-17 16:22 Anonymous (not verified) 174.215.244.78 Mike Benson dba Standard Drywall Proprietorship 1713 w7th st. Waterloo iowa 50702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-17 Michael Arlyn Benson mikekimbenson@gmail.com Waterloo Black Hawk Iowa Leesa Marie Wheeler Austin Michael Thorpe Signed (1) The employer does not elect the employers’ liability coverage. Michael Arlyn Benson mikekimbenson@gmail.com Self Waterloo Black Hawk Iowa Leesa Marie Wheeler Austin Michael Thorpe Signed
1148 2022-06-08 11:41 Anonymous (not verified) 70.96.153.153 Brody Willet LLC Limited Liability Company 244 #rd Ave N, Alburnett, IA 52202 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-08 Brody Willet brody@optionsexteriors.com Alburnett Linn County Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Brody Willet brody@optionsexteriors.com Owner Alburnett Linn County Iowa Charlotte Rasmussen Austin Miller Signed
1152 2022-06-13 13:05 Anonymous (not verified) 70.96.153.153 Tyler Ankney Proprietorship 1250 A Ave, Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-13 Tyler Ankney tyler.a@optionsexteriors.com Marion Linn County Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Tyler Ankney tyler.a@optionsexteriors.com Owner Marion Linn County Iowa Charlotte Rasmussen Austin Miller Signed
1238 2022-08-02 10:24 Anonymous (not verified) 70.96.153.153 Matthew Smith Proprietorship 2070 Golfview Ct, Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Matthew Smith matt.s@optionsexteriors.com Marion Linn Iowa Charlotte Rasmussen Aus Signed (1) The employer does not elect the employers’ liability coverage. Matthew Smith matt.s@optionsexteriors.com Self/Owner Marion Linn Iowa Charlotte Rasmussen Austin Miller Signed
1263 2022-08-16 13:18 Anonymous (not verified) 70.96.153.153 Sinnott Solutions LLC Limited Liability Company 1798 643rd Ln, Albia, IA 52531 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Kyle Sinnott kyle.s@optionsexteriors.com Albia Monroe County Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Kyle Sinnott kyle.s@optionsexteriors.com Owner/Self Albia Monroe Iowa Charlotte Rasmussen Austin Miller Signed
1326 2022-10-04 10:27 Anonymous (not verified) 70.96.153.153 Bright Fame Inc Limited Liability Company 2185 NW 149th St, 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. 2022-10-04 Robert Ferguson robert@optionsexteriors.com Clive Dallas Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Robert Ferguson robert@optionsexteriors.com Owner/Self Clive Dallas Iosa Charlotte Rasmussen Austin Miller Signed
1351 2022-10-31 16:36 Anonymous (not verified) 75.231.74.186 Spencer C Nash LLC Limited Liability Company 4233 Pineview Dr 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. 2022-10-31 Spencer Nash spencer@optionsexteriors.com Cedar Rapids Linn County Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Spencer Nash spencer@optionsexteriors.com Owner/Self Cedar Rapids Linn County Iowa Charlotte Rasmussen Austin Miller Signed
1374 2022-11-17 14:33 Anonymous (not verified) 72.106.129.202 Cowman Consulting and Construction LLC Limited Liability Company 740 NE Horizon Dr, Waukee IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-17 Khalid Cowman khalidcowman1@gmail.com Waukee Dalls Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Khalid Cowman khalidcowman1@gmail.com Self/Owner Waukee Dallas Iowa Charlotte Rasmussen Austin Miller Signed
1573 2023-04-14 13:43 Anonymous (not verified) 94.188.205.167 Jaxon Kressley Proprietorship 954 Boston Way, #12, Corralville, 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. 2023-04-14 Jaxon Kressley jaxon@optionsexteriors.com Corralville Johnson Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Jaxon Kressley jaxon@optionsexteriors.com Owner/Self Corralville Johnson Iowa Charlotte Rasmussen Austin Miller Signed
933 2022-02-23 10:57 Anonymous (not verified) 104.37.139.87 Jacobsen Transfer Limited Liability Company 1773 20th rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-23 Austin Moffat austinmoffatt@gmail.com tabor von homme south dakota austin moffatt jesse jacobsen Signed (1) The employer does not elect the employers’ liability coverage. Jesse Jacobsen jacobsentransfer@gmail.com employee bancorft cuming Nebraska Jesse Jacobsen Austin moffatt Signed
1289 2022-09-01 11:06 Anonymous (not verified) 104.222.95.52 Alliant Personnel Resources Limited Liability Company 619 N Carroll St, Carroll, IA 51401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-01 Jonathan Sturm Jon@AlliantPR.com Carroll, IA Carroll County IA Sara Beiter Austin Scott Signed (1) The employer does not elect the employers’ liability coverage. Jon Sturm Jon@AlliantPR.com Owner Carroll, IA Carroll County Iowa Sara Beiter Austin Scott 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
875 2022-01-31 11:00 Anonymous (not verified) 173.31.102.93 Jhk Construction LLC Limited Liability Company 6203 Casey Ct NE cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Edward Charles Loehr jhkcostruction10@gmail.com Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr Signed (1) The employer does not elect the employers’ liability coverage. Jhk Construction LLC jhkconstruction10@gmail.com Owner Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr Signed
1078 2022-04-28 16:04 Anonymous (not verified) 207.32.54.103 Juilfs Trucking Proprietorship 709 S Geneva St. Pomeroy, IA 50575 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-28 Terry Juilfs sarah_burke7274@hotmail.com Pomeroy Calhoun Iowa Lorie Gerdes Autumn Ramthun Signed (1) The employer does not elect the employers’ liability coverage. Terry Juilfs sarah_burke7274@hotmail.com Myself Pomeroy IA United States Lorie Gerdes Autumn Ramthun Signed
544 2021-06-21 16:10 Anonymous (not verified) 97.125.169.60 Tenant Improvement Services, LLC Limited Liability Company 3011 Justin Drive, Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-21 Jake Etter jake@tenantimprovemetnsiowa.com Polk City Polk Iowa Ashley Overton Aylah Etter Signed (1) The employer does not elect the employers’ liability coverage. Jake Etter jake@tenantimprovementsiowa.com Member Polk City Polk Iowa Ashley Overton Aylah Etter Signed
343 2020-12-28 10:46 Anonymous (not verified) 173.18.204.82 Shelly Hildebrand Proprietorship 424 E 44th St Pleasant Hill 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. 2020-12-28 Shelly Hildebrand centraliowacleaningservice@mediacombb.net Pleasant Hill Polk Iowa Cathy Stevens Bailey Hildebrand Signed (1) The employer does not elect the employers’ liability coverage. Shelly Hildebrand centraliowacleaningservice@mediacombb.net Self Pleasant Hill Polk Iowa Cathy Stevens Bailey Hildebrand Signed
1395 2022-12-15 08:02 Anonymous (not verified) 172.58.84.122 Sehic G&S, LCC Limited Liability Company 4201 62nd st Urbandale iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-15 Bajro sehic kalesija20@gmail.com Urbandale Polk Iowa Bajro Bajro Signed (1) The employer does not elect the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Dallas Iowa Bajro Bajro Signed
1729 2023-07-09 15:33 Anonymous (not verified) 94.188.207.223 Melvin A mineros Limited Liability Company 6209 Windsor dr des moines IA 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-09 Melvin A mineros minerosframing.llc@gmail.com Des moines Polk IA Orlando dominguez Isaac salazar Signed (1) The employer does not elect the employers’ liability coverage. Jaime leiva jaime@boersmaninsurance.com Agent Des moines Polk IA Narciso hidalgo Balmore perez Signed
1778 2023-08-03 14:52 Anonymous (not verified) 94.188.207.227 Melvin A mineros Limited Liability Company 6209 Windsor dr des moines IA 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-06-22 Melvin alexander mineros minerosframing.llc@gmail.com Des moines Polk IA Orlando dominguez Isaac salazar Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jaime leiva jaime@boersmaninsurance.com Agent Des moines Polk IA Narciso hidalgo Balmore perez Signed
293 2020-10-28 06:58 Anonymous (not verified) 173.189.165.102 Boettcher Construction Proprietorship PO Box 482, 843 West Business 30 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-28 otto p boettcher obc32@live.com Lisbon IA iowa Barb Boettcher Barb Boettcher Signed (1) The employer does not elect the employers’ liability coverage. otto p boettcher obc32@live.com same person Lisbon IA iowa Barb Boettcher Barb Boettcher 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
311 2020-11-10 10:42 Anonymous (not verified) 75.162.206.98 Menz Construction, LCC Limited Liability Company 304 SW Clark Lane, Grimes, Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-10 Jeff Menz construction.menz@gmail.com Grimes Polk Iowa Janelle Menz Barb Menz Signed (1) The employer does not elect the employers’ liability coverage. David Finneseth david.finneseth@fbfs.com Agent Perry Dallas Iowa Janelle Menz Barb Menz Signed
98 2020-03-23 15:07 Anonymous (not verified) 65.120.236.250 Cross Roads Logistics, LLC Limited Liability Company 3103 21st St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-23 Mark Alan Cross rcreek2016@gmail.com Davenport IA IA Lori Ann Cross Barbara A Deering Signed (1) The employer does not elect the employers’ liability coverage. Mark Alan Cross rcreek2016@gmail.com President/Owner Davenport IA IA Lori Ann Cross Barbara A Deering Signed
609 2021-08-17 21:42 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, IA. 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-17 Zackery James VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Barbara M VanderBeek James. VanderBeek Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA James D VanderBeek Barbara M VanderBeek Signed
690 2021-10-26 14:23 Anonymous (not verified) 65.144.174.26 Santiago Rojas Proprietorship 1359 22nd st Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-26 Santiago Rojas rojassr09@gmail.com Des Moines Polk Iowa David Rojas Beatriz Hernandez Signed (1) The employer does not elect the employers’ liability coverage. Santiago Rojas rojassr09@gmail.com Owner Des Moines Polk Iowa David Rojas Beatriz Hernandez Signed
1746 2023-07-14 09:21 Anonymous (not verified) 94.188.205.176 Alex Webb Proprietorship 4019 West Roderweis Road Cabot Ar 72023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-14 Alex Webb frankie.webb@yahoo.com Cabot Pulaski Arkansas Mark Ellis Becky Ellis Signed (1) The employer does not elect the employers’ liability coverage. Ellis Flying Service INC. fly@ellisflying.com President Newport Arkansas United States Alex Webb Becky Ellis Signed
1387 2022-12-10 22:39 Anonymous (not verified) 98.156.163.144 Springfield Staffing Solution Limited Liability Company 14918 Tuff Rd, Manor TX 78653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-10 Beluchukwu Ebede admin@springfield-staffing.com Manor Travis United States Oluchukwu Nwokoye Beluchukwu Ebede Signed (1) The employer does not elect the employers’ liability coverage. Beluchukwu Ebede admin@springfield-staffing.com Self Manor Travis United States Oluchukwu Nwokoye Beluchukwu Ebede Signed
1350 2022-10-31 10:42 Anonymous (not verified) 108.160.48.9 gaes trucking Proprietorship 84642 Dun Rd Norfolk, NE 68701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 SHANE GAES scgaes@icloud.com Norfolk NE United States Bill Rich Ben Becker Signed (1) The employer does not elect the employers’ liability coverage. shane gaes scgaes@icloud.com self norfolk pierce county nebraska nebraska Bill Rich Ben Becker Signed
734 2021-11-11 14:05 Anonymous (not verified) 72.13.16.172 REDFEARN TRUCKING INC Proprietorship 5512 WEST STAGECOACH 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. 2019-11-18 REDFEARN TRUCKING INC dave@allseasonstrucking.com GALENA JODAVIES IL DAVE NEUWOHNER BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. REDFEARN TRUCKING INC dave@allseasonstrucking.com PRESIDENT GALENA JODAVIES IL DAVE NEUWOHNER BEN MOYER Signed
735 2021-11-11 14:10 Anonymous (not verified) 72.13.16.172 T MILLER TRUCKING LLC Limited Liability Company 1682 MONROE DRIVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 T MILLER TRUCKING LLC DAVE@ALLSEASONSTRUCKING.COM WATERVILLE ALLAMAKEE IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. T MILLER TRUCKING LLC dave@allseasonstrucking.com PRESIDENT WATERVILLE ALLAMAKEE IA Dave Neuwohner BEN MOYER Signed
736 2021-11-11 14:26 Anonymous (not verified) 72.13.16.172 All Seasons Trucking Inc Proprietorship S11689 CTY RD G I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 FARGEN TRUCKING dave@allseasonstrucking.com SPRING GREEN SAUK WI DAVE NEUWOHNER BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. FARGEN TRUCKING DAVE@ALLSEASONSTRUCKING.COM PRESIDENT SPRING GREEN SAUK WI Dave Neuwohner BEN MOYER Signed
737 2021-11-11 14:33 Anonymous (not verified) 72.13.16.172 BADGER COUNTRY TRUCKING LLC Limited Liability Company 3877 US HWY 35 AND 61 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-13 BADGER COUNTRY TRUCKING LLC dave@allseasonstrucking.com POTOSI GRANT WI Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. BADGER COUNTRY TRUCKING LLC dave@allseasonstrucking.com PRESIDENT POTOSI GRANT WI Dave Neuwohner BEN MOYER Signed
738 2021-11-11 14:38 Anonymous (not verified) 72.13.16.172 MARK ALAN SALATHE Proprietorship 1042 WELLS 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. 2019-11-18 MARK ALAN SALATHE dave@allseasonstrucking.com DARLINGTON LAFAYETTE WI Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. MARK ALAN SALATHE dave@allseasonstrucking.com PRESIDENT DARLINGTON LAFAYETTE WI DAVE NEUWOHNER BEN MOYER Signed
739 2021-11-11 14:46 Anonymous (not verified) 72.13.16.172 WILLIAM THIAS Proprietorship PO BOX 152 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 WILLIAM THIAS dave@allseasonstrucking.com CLERMONT FAYETTE IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. WILLIAM THIAS dave@allseasonstrucking.com PRESIDENT CLERMONT FAYETTE IA Dave Neuwohner BEN MOYER Signed
740 2021-11-11 14:54 Anonymous (not verified) 72.13.16.172 LECHTENBERG TRUCKING LLC Limited Liability Company 10185 HWY 18 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 LECHTENBERG TRUCKING LLC dave@allseasonstrucking.com POSTVILLE CLAYTON IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. LECHTENBERG TRUCKING LLC dave@allseasonstrucking.com PRESIDENT POSTVILLE CLAYTON IA Dave Neuwohner BEN MOYER Signed
741 2021-11-11 15:09 Anonymous (not verified) 72.13.16.172 RICK VANGORDER Proprietorship 2549 QUASQUETON DIAGONAL BLVD I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 RICK VANGORDER dave@allseasonstrucking.com INDEPENDENCE BUCHANAN IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. RICK VANGORDER dave@allseasonstrucking.com PRESIDENT INDEPENDENCE BUCHANAN IA Dave Neuwohner BEN MOYER Signed
742 2021-11-11 15:14 Anonymous (not verified) 72.13.16.172 JACOB WESLEY JOHNSON Proprietorship 1306 BAXTER 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. 2019-11-18 JACOB WESLEY JOHNSON dave@allseasonstrucking.com FAIRBANK BUCHANAN IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. JACOB WESLEY JOHNSON dave@allseasonstrucking.com PRESIDENT FAIRBANK BUCHANAN IA Dave Neuwohner BEN MOYER Signed
743 2021-11-11 15:19 Anonymous (not verified) 72.13.16.172 ROLING TRANSPORT LLC Limited Liability Company 33041 395TH 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. 2019-11-18 ROLING TRUCKING LLC dave@allseasonstrucking.com BELLEVUE JACKSON IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. ROLING TRUCKING LLC dave@allseasonstrucking.com PRESIDENT BELLEVUE JACKSON IA Dave Neuwohner BEN MOYER Signed
744 2021-11-11 15:22 Anonymous (not verified) 72.13.16.172 MJL TRANSPORT Proprietorship PO BOX 3301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 MJL TRANSPORT dave@allseasonstrucking.com DUBUQUE DUBUQUE IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. MJL TRANSPORT dave@allseasonstrucking.com PRESIDENT DUBUQUE DUBUQUE IA Dave Neuwohner BEN MOYER Signed
745 2021-11-11 15:24 Anonymous (not verified) 72.13.16.172 SCHLECHT TRUCKING LLC Limited Liability Company 107 SOUTH 1ST 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. 2019-11-18 SCHLECHT TRUCKING LLC dave@allseasonstrucking.com SPRINGBROOK JACKSON IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. SCHLECHT TRUCKING LLC dave@allseasonstrucking.com PRESIDENT SPRINGBROOK JACKSON IA Dave Neuwohner BEN MOYER Signed
471 2021-04-13 10:35 Anonymous (not verified) 65.103.82.36 River City Floors Proprietorship 2114 N Zenith 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. 2020-05-30 Brad Ernest Dahl na@noemail.com Davenport Scott IA Dawn T Ben S Signed (1) The employer does not elect the employers’ liability coverage. Brad Dahl na@noemail.com Owner Davenport Scott IA Dawn T Ben S Signed
1236 2022-08-01 20:06 Anonymous (not verified) 24.149.20.39 Jake's Insulation Proprietorship 2020 Valley High 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. 2022-08-01 Jacob Ryan Smalley jakersmalley@gmail.com Cedar Falls USA Iowa Emily Smalley Ben Smalley Signed (1) The employer does not elect the employers’ liability coverage. Jacob Ryan Smalley jakersmalley@gmail.com Owner Cedar Falls USA Iowa Emily Smalley Ben Smalley Signed
814 2021-12-27 13:07 Anonymous (not verified) 216.51.155.17 I & B Ag Supply, LLC Limited Liability Company 3807 20th Ave Fenton, IA 50539 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-27 Israel Winter israel.winter@hotmail.com Fenton Kossuth Iowa Jonathan Gesink Benjamin Wiersma Signed (1) The employer does not elect the employers’ liability coverage. Israel Winter israel.winter@hotmail.com Member Fenton Kossuth Iowa Jonathan Gesink Benjamin Wiersma Signed
1997 2024-01-25 11:09 Anonymous (not verified) 94.188.207.225 Abstract Associates of Iowa Inc. Proprietorship 822 Central Ave Ste 304 Fort Dodge, IA 50501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-21 Ted Hugghins tjhugghins@abstractassociatesofiowa.com Fort Dodge Webster Iowa Mariah Ayala Bennett O'Connor Signed (1) The employer does not elect the employers’ liability coverage. Ted Hugghins tjhugghins@abstractassociatesofiowa.com President Fort Dodge Webster IA Mariah Ayala Bennett O'Connor Signed
1689 2023-06-13 19:55 Anonymous (not verified) 94.188.207.227 Gerardo Reyes-Lopez Limited Liability Company 908 West 1st Street, Waterloo, IA ,50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-13 Gerardo Reyes-lopez greyeslopez9@gmail.com Waterloo Black Hawk Iowa Guillermina Lopez Bernardo Reyes Signed (1) The employer does not elect the employers’ liability coverage. Denise Seitsinger denise@harmsinsuranceagency.com Insurance Agent Sumner Bremer Iowa Gerardo Reyes Bernardo Reyes Signed
1690 2023-06-13 20:01 Anonymous (not verified) 94.188.207.227 Gerardo Reyes-Lopez Limited Liability Company 908 West 1st Street, Waterloo, Iowa, 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-13 Gerardo Reyes-lopez bernardo@reyesconstruct.com Waterloo IA United States Guillermina Lopez Bernardo Reyes Signed (1) The employer does not elect the employers’ liability coverage. Denise Seitsinger denise@harmsinsuranceagency.com Insurance Agent Sumner Bremer Iowa Gerardo Reyes Bernardo Reyes Signed
664 2021-10-05 15:01 Anonymous (not verified) 174.242.226.8 New Face Renovations Limited Liability Company 3563 Richland Circle Van Meter, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-05 Darin Benjamin Davis newfacereno@gmail.com Van Meter Dallas Iowa Ryan Young Betsy Davis Signed (1) The employer does not elect the employers’ liability coverage. Renda Building megemo@commdatalink.com Installer Grimes Polk Iowa Ryan Young Betsy Davis Signed
602 2021-08-13 22:49 Anonymous (not verified) 208.38.230.125 Granite & More Limited Liability Company 4730, Tremont Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-14 Jin Chen clteam563@gmail.com Davenport IA United States Jin Chen Betty Song Signed (1) The employer does not elect the employers’ liability coverage. Hong Le clteam563@gmail.com Self Davenport Scott Iowa Jin Chen Betty Song Signed
1719 2023-07-01 21:34 Anonymous (not verified) 94.188.207.223 Granite & More Limited Liability Company 4730 Tremont ave Davenport Iowa 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-01 Hong Le granite732@yahoo.com Davenport Scott Iowa Jin Chen Betty Song Signed (1) The employer does not elect the employers’ liability coverage. Jin Chen clteam563@gmail.com Manager Bettendorf Scott Iowa Jin Chen Betty Song Signed
1837 2023-09-11 19:10 Anonymous (not verified) 94.188.207.230 TBA Handyman service Limited Liability Company 619 e 10th st. north newton Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-11 Joey Conkling tba050402@gmail.com newton jasper Iowa Ashton tyler conkling Bianca Storm Conkling Signed (1) The employer does not elect the employers’ liability coverage. TBA Handyman Service tbaconstruction02@gmail.com self newton jasper iowa Ashton tyler Conkling Bianca Storm Conkling Signed
53 2020-02-06 11:09 Anonymous (not verified) 65.100.22.228 Bostian Captioning Service, Inc. Proprietorship 712 8th Avenue NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-06 Dana Bostian danabostian@msn.com Oelwein IA United States Lynne Koch Billie Winters Signed (1) The employer does not elect the employers’ liability coverage. Dana Bostian danabostian@msn.com President of Proprietorship Oelwein IA United States Lynne Koch Billie Winters Signed
612 2021-08-19 21:50 Anonymous (not verified) 50.82.65.174 33z Racing,, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 James Dean VanderBeek jvanderbeek@plbco.com New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed
613 2021-08-19 21:54 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 Zackery J VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed
1160 2022-06-20 10:08 Anonymous (not verified) 138.43.237.249 High Caliber Fiber Limited Liability Company 2958 110th ave masonville IA, 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-20 chris cooper Chris_cooper@highcaliberfiber.com Masonville Delaware IA Laura Rose Lentz Blake Dean Elbert Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper Chris_cooper@highcaliberfiber.com self Masonville Delaware IA Laura Rose Lentz BLake Dean Elbert 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
499 2021-04-28 08:05 Anonymous (not verified) 167.142.98.81 Bents Consulting LLC Limited Liability Company 2147 160th Street Boone Iowa 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-28 Jeremy D Bents help@bentsconsulting.com Boone Boone Iowa Derek Hanson Bob Clements Signed (1) The employer does not elect the employers’ liability coverage. Jeremy D Bents help@bentsconsulting.com Owner Boone Boone Iowa Derek Hanson Bob Clements Signed
1924 2023-11-27 12:17 Anonymous (not verified) 94.188.205.166 Leaf Home LLC Limited Liability Company 1595 Georgetown Rd. Hudson, OH 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-27 Nathaniel Brundidge nateotto1313@gmail.com Osceola Warren IA Barb Dryer Bob Dryer Signed (1) The employer does not elect the employers’ liability coverage. Monica Acosta macosta@leafhome.com Employee Hudson Summit Ohio Barb Dryer Bob Dryer Signed
4 2019-11-12 09:06 Anonymous (not verified) 174.71.54.19 M AND J LLC Limited Liability Company 44100 STATE HIGHWAY 37 Dunlap, IA 51529 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-12 Mark Nichols mknichols2003@yahoo.com DUNLAP Monona IA Damon Nichols Bob Hall Signed (1) The employer does not elect the employers’ liability coverage. Mark Nichols mknichols2003@yahoo.com Partner Dunlap Monona IA Damon Nichols Bob Hall Signed
5 2019-11-12 09:57 Anonymous (not verified) 174.71.54.19 M AND J LLC Limited Liability Company 44100 STATE HIGHWAY 37 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-12 M AND J, LLC mknichols2003@yahoo.com DUNLAP MONONA IA Damon Nichols Bob Hall Signed (1) The employer does not elect the employers’ liability coverage. JAMES MUMM plipichok@yahoo.com Partner DUNLAP MONONA IA DAMON NICHOLS BOB HALL Signed
1042 2022-04-12 10:10 Anonymous (not verified) 173.20.170.177 Yaseen Albayati Proprietorship 615 park st apt 1511 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-12 Yaseen Albayati yaseenali53@gmail.com Des Moines Polk Iowa Alexis Bagas Bob Pankrukhin Signed (1) The employer does not elect the employers’ liability coverage. Yaseen Albayati yaseenali53@gmail.com self Des Moines polk Iowa Alexis Bagas Bob Pankrukhin Signed
140 2020-04-28 10:13 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-21 John D Noel chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed (1) The employer does not elect the employers’ liability coverage. John D Noel chelsea.whalen@upperiowains.com President Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed
142 2020-04-28 10:16 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 Timothy A Stoddard chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed (1) The employer does not elect the employers’ liability coverage. Timothy A Stoddard chelsea.whalen@upperiowains.com Treasurer Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed
1045 2022-04-13 09:55 Anonymous (not verified) 192.119.237.126 BARGAIN HOUSE Proprietorship 11 S FREDERICK AVE, OELWEIN, IA 50662 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-13 RICHARD M. BECKER SHELBY@CIOIA.COM HAZLETON BUCHANAN IOWA SHELBY S. WILLIAMS BOBBIE J. BERGAN Signed (1) The employer does not elect the employers’ liability coverage. RICHARD M. BECKER SHELBY@CIOIA.COM OWNER OELWEIN FAYETTE IOWA SHELBY S. WILLIAMS BOBBIE J. BERGAN Signed
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
1634 2023-05-10 07:21 Anonymous (not verified) 94.188.205.174 KS Drywall Proprietorship 404 E Jayne Street Lone Tree, IA 52755 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Kirk Strunk kirkstrunk@gmail.com Lone Tree Johnson Iowa Chris Hay Brad Bower Signed (1) The employer does not elect the employers’ liability coverage. Kirk Strunk kirkstrunk@gmail.com Self Lone Tree Johnson Iowa Chris Hay Brad Bower Signed
1643 2023-05-12 07:56 Anonymous (not verified) 94.188.205.169 Smooth Finish Drywall Proprietorship 3111 115th 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. 2023-05-12 Seth T Mize II stmize@hotmail.com Riverside Washington Iowa Chris Hay Brad Bower Signed (1) The employer does not elect the employers’ liability coverage. Seth T Mize II stmize@hotmail.com Self Riverside Washington Iowa Chris Hay Brad Bower Signed
1645 2023-05-12 14:48 Anonymous (not verified) 94.188.207.225 VL Drywall LLC Limited Liability Company 1608 6th Ave SE Cedar Rapids I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-12 LESLIE LEYVA lleyva9696@gmail.com Cedar Rapids LINN Iowa Brad Bower Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Leslie Leyva lleyva9696@gmail.com Self Cedar Rapids Linn Iowa Chris Hay Brad Bower Signed
1809 2023-08-21 07:55 Anonymous (not verified) 94.188.207.228 Gonzalez Drywall LLC Limited Liability Company 323 Friendhip St Apt 3, Iowa City, IA 52245 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-21 Leonel Angel Gonzalez victorangel8373@gmail.com Iowa City Johnson Iowa Chris Hay Brad Bower Signed (1) The employer does not elect the employers’ liability coverage. Leonel Angel Gonzalez victorangel8373@gmail.com Self Iowa City Johnson Iowa Chris Hay Brad Bower Signed
1262 2022-08-16 12:52 Anonymous (not verified) 74.137.151.70 Golds Custom Grading LLC Limited Liability Company Po Box 114 Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-16 Brad Carlson brad_carlson@gmail.com Spencer Clay Iowa Thomas Dunn Nancy Cassa Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Thomas Dunn TDUNN@THOMASBRADLEYINSURANCE.COM Agent Madison Dane Wisconsin Nancy Cassa Brad Carlson Signed
1881 2023-10-26 14:10 Anonymous (not verified) 94.188.205.175 McAninch Painting LLC Limited Liability Company 2422 Richmond 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. 2023-10-26 Brian McAninch brian@allcoatfinishes.com Des Moines Polk Iowa Kane Fairman Brad Sandstoe Signed (1) The employer does not elect the employers’ liability coverage. Brian McAninch brian@allcoatfinishes.com Self Des Moines polk Iowa Kane Fairman Brad Sandstoe Signed
1397 2022-12-21 14:05 Anonymous (not verified) 50.81.162.60 Jesse Iseminger Proprietorship 3117 e 40th ct, Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-21 Jesse Iseminger Jesseiseminger@gmail.com Des Moines Polk Iowa Shelly Johns Brad Weikert Signed (1) The employer does not elect the employers’ liability coverage. Jesse Iseminger Jesseiseminger@gmail.com Self Des Moines Iowa Iowa Shelly Johns Brad Weikert 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
902 2022-02-07 11:53 Anonymous (not verified) 65.144.174.26 Donald Gardner Jr. Proprietorship 625 NE 72nd Street, Pleasant Hill, Iowa 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. 2022-02-07 Donald Gardner, Jr. dnagardner95@yahoo.com Pleasant Hill Polk Iowa Andrew West Braden Collins Signed (1) The employer does not elect the employers’ liability coverage. Donald Gardner, Jr. dnagardner95@yahoo.com Owner Pleasant Hill Polk Iowa Andrew West Braden Collins Signed
833 2022-01-12 17:30 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-13 Steven John Swanson studio7sjs@gmail.com Cedar Falls Black Hawk County Iowa Kari Houle Braden L Gray Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Braden L Gray Signed
838 2022-01-13 17:53 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-13 Darren Dean Fanning dschmanning@gmail.com Cedar Falls Black Hawk County Iowa Kari Houle Braden L Gray Signed (1) The employer does not elect the employers’ liability coverage. Cory Allen Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Braden L Gray Signed
470 2021-04-13 09:34 Anonymous (not verified) 173.21.135.56 JNZ Recruiting LLC Limited Liability Company 703 Washington St. Williamsburg, IA 52361 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-04-07 Javier Nevarez amanda@burginsuranceagency.com Williamsburg IA IA Amanda Clubb Bradley Schaefer Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Javier Nevarez amanda@burginsuranceagency.com Self Williamsburg Iowa Iowa Amanda Clubb Bradley Schaefer Signed
1915 2023-11-21 04:06 Anonymous (not verified) 94.188.207.225 Advanced Foam Systems Limited Liability Company 1378 Midway Ave Tripoli IA 50676 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-18 Randy Block advancedfoamsystems@yahoo.com Tripoli Bremer Iowa Linda Block Brady Block Signed (1) The employer does not elect the employers’ liability coverage. Randy Block advancedfoamsystems@yahoo.com Me Tripoli Bremer Iowa Linda block Brady block Signed
2167 2024-04-21 22:01 Anonymous (not verified) 94.188.205.177 The Duerson Corportaion Proprietorship 601 1st Ave N, Altoona, IA 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-21 Nicholas John Myers myersnicholasj@gmail.com Norwalk IA United States Theresa Myers Bradyn Smith Signed (1) The employer does not elect the employers’ liability coverage. Nicholas John Myers myersnicholasj@gmail.com Owner Norwalk IA United States Theresa Myers Bradyn Smith Signed
89 2020-03-13 12:41 Anonymous (not verified) 216.96.113.16 B’s Sweet Treats Proprietorship 123 E Marion St. Sigourney IA 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-13 Brandi Wehr brndwehr54@hotmail.com Sigourney Keokuk IA Brandi Brandi Signed (1) The employer does not elect the employers’ liability coverage. Brandi Wehr brndwehr54@hotmail.com Same Sigourney Keokuk IA Brandi Brandi Signed
1919 2023-11-21 14:11 Anonymous (not verified) 94.188.207.227 Refined Construction Limited Liability Company 4148 Mattern 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. 2023-11-21 Dustin Martin dudtin.martin106@gmail.com Des Moines Polk IA Kelsey Baldinelli Brandi Martin Signed (1) The employer does not elect the employers’ liability coverage. Dustin Martin dustin.martin106@gmail.com Sole officer Des Moines Polk IA Kelsey Baldinelli Brandi Martin Signed
568 2021-07-09 09:26 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company P.O. Box 561 Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow k.kooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC k.kooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
570 2021-07-09 16:42 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company P.O. Box 561 Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow kkooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC kkooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
593 2021-08-03 12:29 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company PO Box 561, Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow k.kooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC k.kooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
1835 2023-09-09 15:11 Anonymous (not verified) 94.188.207.224 Heartland Ultrasonography Group Limited Liability Company 1015 Woodland Dr 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. 2023-09-09 Micah Ezra Wiele mewiele99@gmail.com Ankeny Polk Iowa Nathan Miguel Diaz Brandon Allen Pemoulie Signed (1) The employer does not elect the employers’ liability coverage. Micah Ezra Wiele heartlandusgroup@outlook.com Co-owner Ankeny Polk Iowa Nathan Miguel Diaz Brandon Allen Pemoulie Signed
1797 2023-08-14 09:37 Anonymous (not verified) 94.188.205.175 SCG Limited Liability Company 307 Bridge St. Redfield, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-01 David Dwight Willis d.dubbaits@yahoo.com Redfield Dallas Iowa Lindsey Willis Sam Samuelson Signed (1) The employer does not elect the employers’ liability coverage. Ross Turner RTurner@holmesmurphy.com Agent Waukee Dallas Iowa Brain Paterson Brandon DeGroff Signed
519 2021-05-13 10:32 Anonymous (not verified) 50.82.22.159 Southern Iowa Crane, Incorporated Proprietorship 635 Mill Street; 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. 2021-05-13 Steve Lee southerniowacraneinc@hotmail.com Ottumwa Wapello Iowa Brandon Gravett Sarah Gravett Signed (1) The employer does not elect the employers’ liability coverage. Steve Lee sotherniowacraneinc@hotmail.com Self Ottumwa Wapello Iowa Sarah Gravett Brandon Gravett Signed
647 2021-09-20 10:37 Anonymous (not verified) 173.29.34.49 Brandon Jones Proprietorship 2043 3x Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-20 Brandon Dederick Jones Kaleb0430jones@gmail.com East Moline United States Illinois Brandon Jones Brandon Jones Signed (1) The employer does not elect the employers’ liability coverage. Brandon Dederick Jones Kaleb0430jones@gmail.com self East Moline United States Illinois Brandon Jones Brandon Jones Signed
580 2021-07-22 10:40 Anonymous (not verified) 72.13.27.253 Gudenkauf Tiling & Excavating LLC Limited Liability Company 1840 275th St Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Terry Thomas Gudenkauf tlgudenkauf@yousq.net Manchester Delaware IA Lisa Gudenkauf Brandon Mather Signed (1) The employer does not elect the employers’ liability coverage. Terry Gudenkauf tlgudenkauf@yousq.net Owner MAnchester IA United States Lisa Gudenkauf Brandon Mather Signed
2047 2024-02-15 16:58 Anonymous (not verified) 94.188.205.177 PorchLight Insights LLC Limited Liability Company 2918 Campbell Street, Kansas City, MO 64109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-15 Kate Regnier Bender kate.bender@porchlightinsights.com Kansas City Jackson Missouri Jonathan Bender Brandon Steenson Signed (1) The employer does not elect the employers’ liability coverage. Kate Regnier Bender kate.bender@porchlightinsights.com Co-Founder Kansas City Jackson Missouri Jonathan Bender Brandon Steenson Signed
432 2021-03-11 18:17 Anonymous (not verified) 99.196.90.45 A-Z Tree Service Proprietorship 1128 W 124th St 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. 2021-03-11 Daniel Keeney dansatoztreeservice@gmail.com Colfax Jasper Iowa David Short Brandon Vriezlaar Signed (1) The employer does not elect the employers’ liability coverage. Daniel Keeney dansatoztreeservice@gmail.com Sole Proprietor Colfax Jasper Iowa David Short Brandon Vriezlaar Signed
665 2021-10-06 09:22 Anonymous (not verified) 192.96.173.171 Michael Childers Proprietorship 21 N.6th street savanna Illinois I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-06 Michael Childers peddler73@hotmail.com Savanna Carroll Illinois Brandy arnold Jordan nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Jordan nisiewicz jnisiewicz@leafhome.com Recruiter Kansas city Clay Mo Jordan nisiewicz Brandy arnold Signed
448 2021-03-25 10:18 Anonymous (not verified) 172.58.83.161 Limited Liability Company 201 Ne 44th St , Apt 111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-25 Aldo Monroy reyes Aldogmonroy@gmail.com Ankeny Polk county IOWA Elizabeth lopez Brayan monroy Signed (1) The employer does not elect the employers’ liability coverage. Aldo Monroy Aldogmonroy@gmail.com None Ankeny Polk county IOWA Aldo Monroy Brayan monroy Signed
1846 2023-09-15 13:25 Anonymous (not verified) 94.188.207.224 Kg Roofing Limited Liability Company 1820 1 Ave S, Fort Dodge IA 50501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-09-15 Tyler Price tylerprice636@gmail.com Fort Dodge Webster IOWA Ashley Bates Breann Moore Signed (1) The employer does not elect the employers’ liability coverage. Tyler tylerprice636@gmail.com Self Fort Dodge Webster IOWA Ashley Bates Breann Moore Signed
2067 2024-02-29 16:58 Anonymous (not verified) 94.188.205.166 James Baker Limited Liability Company 1510 E 1st 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. 2024-01-01 James Baker jaykeribaker@yahoo.com Indianola Warren IA Keri Baker Brenan Baker Signed (1) The employer does not elect the employers’ liability coverage. James Baker jaykeribaker@yahoo.com Self Indianola Warren IA Keri Baker Brenan Baker Signed
2038 2024-02-08 07:44 Anonymous (not verified) 94.188.205.167 Travis Toney Limited Liability Company 932 w12th street south 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. 2024-02-08 Travis Duane Toney travistoney1984@gmail.com Newton United States IA Rick lee Toney Brenda Ann Toney Signed (1) The employer does not elect the employers’ liability coverage. Phil glazer kg_Info@capitallandscaping.com Contractor Des Moines United States IA Rick lee Toney Brenda Ann Toney Signed
1711 2023-06-26 16:50 Anonymous (not verified) 94.188.207.224 Innovative Behavioral Therapy, LLC Limited Liability Company 915 Main St. Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-26 Ashley Andrew ashley@innovativebehavioraltherapy.com Adel Dallas Iowa Thomas Atherton Brenda Barto Signed (1) The employer does not elect the employers’ liability coverage. Ashley Andrew ashley@innovativebehavioraltherapy.com Self Adel Dallas Iowa Thomas Atherton Brenda Barto Signed
935 2022-02-24 09:44 Anonymous (not verified) 174.215.244.252 Cornejo Construction Limited Liability Company 419 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. 2022-02-24 Bulmaro Cornejo cruzcornejo4314@gmail.com Perry Dallas Iowa Jose Cruz Cornejo Andrade Brenda Espinoza Signed (1) The employer does not elect the employers’ liability coverage. Bulmaro Cornejo cruzcornejo4314@gmail.com Owner Perry Dallas Iowa Jose Cruz Cornejo Brenda Espinoza Signed
1720 2023-07-05 07:19 Anonymous (not verified) 94.188.207.224 Doug FGerneding Proprietorship 21618 270th St Carroll IA 51401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-05 Doug Ferneding dougferneding@gmail.com Carroll Iowa Iowa Jaynie Ferneding Brenda Klein Signed (1) The employer does not elect the employers’ liability coverage. Doug Ferneding dougferneding@gmail.com same Carroll Iowa Iowa Jaynie Ferneding Brenda Klein Signed
1760 2023-07-26 08:16 Anonymous (not verified) 94.188.207.230 MCH Pig LLC Limited Liability Company 5434 180th Ave Albert City, IA 50510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-26 Mitchell Hogrefe mhogrefe@nfpinc.com Newell Buena Vista Iowa Kyle Klein Brenda Klein Signed (1) The employer does not elect the employers’ liability coverage. Mitchell Hogrefe mhogrefe@nfpinc.com Owner Newell Buena Vista Iowa Kyle Klein Brenda Klein Signed
2055 2024-02-23 14:54 Anonymous (not verified) 94.188.207.224 Neil Vonnahme Proprietorship 13628 220th St., Arcadia, Iowa, 51430 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-20 Neil Vonnahme neilvonnahme@gmail.com Arcadia Carroll Iowa Kyle Klein Brenda Klein Signed (1) The employer does not elect the employers’ liability coverage. Neil Vonnahme neilvonnahme@gmail.com Self Arcadia Carroll Iowa Kyle Klein Brenda Klein Signed
984 2022-03-18 11:34 Anonymous (not verified) 207.177.116.48 Craig Jacoba Signs Proprietorship 20404 Walnut Street Yarmouth, IA 52660 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Craig Allan Jacoba craigjacoba1@hotmail.com Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed (1) The employer does not elect the employers’ liability coverage. Craig Jacoba craigjacoba1@gmail.com subcontractor Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed
985 2022-03-18 11:39 Anonymous (not verified) 207.177.116.48 Craig Jacoba Signs Proprietorship 20404 Walnut Street Yarmouth, IA 52660 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Craig Allan Jacoba craigjacoba1@hotmail.com Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed (1) The employer does not elect the employers’ liability coverage. Greater Burlington Partnership - Chamber of Commerce amoyner@greaterburlington.com subcontractor Burlington Des Moines Iowa Amy Moyner Brenda Levitt Signed
1713 2023-06-27 09:06 Anonymous (not verified) 94.188.205.175 Ray's Painters, LLC Limited Liability Company 4120 Mount Alpine Street, 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. 2023-05-15 Danny Sexton dsexton766@gmail.com Dubuque Dubuque Iowa Donna Gotto Brenda Lewis Signed (1) The employer does not elect the employers’ liability coverage. Ray's Painters LLC dsexton766@gmail.com insured Dubuque Dubuque Iowa Donna Gotto Brenda Lewis 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
1328 2022-10-07 22:45 Anonymous (not verified) 50.82.178.112 Compass Commercial Services LLC Limited Liability Company 1950 Boyson road, Hiawatha, Ia 52233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-07 Patrick Roland mastershineservices@gmail.com Cedar Rapids Linn Iowa Aubrey Hantz Brenna Trinkle Signed (1) The employer does not elect the employers’ liability coverage. Blake Fortanini bfontanini@compassbuilt.com Project Manager Hiawatha Linn Iowa Aubrey Hantz Brenna Trinkle Signed
914 2022-02-15 10:22 Anonymous (not verified) 206.72.12.83 Custom Windows Plus Limited Liability Company 1623 Rose Avenue Allendorf Iowa 51354 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-15 Elijah Zevenbergen elijah.zevenbergen@gmail.com Allendorf United States IA Andrea Johnson Brennan Krogman Signed (1) The employer does not elect the employers’ liability coverage. Elijah Zevenbergen elijah.zevenbergen@gmail.com Owner Allendorf United States IA Andrea Johnson Brennan Krogman Signed
1223 2022-07-22 15:14 Anonymous (not verified) 167.142.255.81 HomeOwner's Helper LLC Limited Liability Company 111 4th Ave, Underwood, IA 51576 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-22 Bradley W Syndergaard mrslouie8@yahoo.com UNDERWOOD Iowa United States Stacy L Louison Brent C Louison Signed (1) The employer does not elect the employers’ liability coverage. Bradley W Syndergaard mrslouie8@yahoo.com Self UNDERWOOD Iowa United States Stacy L Louison Brent C Louison Signed
1665 2023-05-27 17:41 Anonymous (not verified) 94.188.205.175 Diamond Spray Foam and Coatings LLC Limited Liability Company 19024 345th St, Forest City, IA 50436 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-27 Joshua Gregory Diamond dsfinsulation@gmail.com Forest City Winnebago IA Brett Busenitz Bret Guggisburg Signed (1) The employer does not elect the employers’ liability coverage. Joshua Gregory Diamond dsfinsulation@gmail.com Owner Forest City Winnebago IA Brett Busenitz Bret Guggisburg Signed
751 2021-11-16 15:51 Anonymous (not verified) 166.181.83.87 Dylan Wilson SMS & More Proprietorship 7500 25th Milan IL 61264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-16 Dylan Wilson doe33843@gmail.com Milan Rock Island IL Jamie Short Brett Dawson Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Groech wilsoncrazy@gmail.com Grandmother Moline Rock Island IL Jamie Short Brett Dawson Signed
1682 2023-06-08 17:55 Anonymous (not verified) 94.188.205.174 Jared hoffman Proprietorship 22429 250th st carroll IA 5140q I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-06 Jared Hoffman jhoffman@live.com Carroll Carroll Iowa Jeff dentlinger Brian babb Signed (1) The employer does not elect the employers’ liability coverage. Jared Hoffman jhoffman@live.com Self Carroll Carroll Iowa Jeff dentlinger Brian babb Signed
199 2020-07-09 10:49 Anonymous (not verified) 167.142.98.40 Ryan Stott Proprietorship 1513 Hawthorne Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Ryan Lynn Stott rlstott@hotmail.com Jefferson Greene Iowa Brock Chisum Brian Chisum Signed (1) The employer does not elect the employers’ liability coverage. Ryan Stott rlstott@hotmail.com self Jefferson Greene Iowa Brock Chisum Brian Chisum Signed
1879 2023-10-26 13:17 Anonymous (not verified) 94.188.207.224 CR Exteriors Proprietorship 1636 Parktown Ct NE Unit 9 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-26 corey becker cab222.ab@gmail.com cedar rapids linn iowa Brian Ashlock Brian Coover Signed (1) The employer does not elect the employers’ liability coverage. Corey Becker cab222.ab@gmail.com same Cedar Rapids Linn Iowa Brian Ashlock Brian Coover Signed
563 2021-07-08 12:16 Anonymous (not verified) 173.17.250.209 Forest Avenue Outreach Limited Liability Company 1600 6th Ave DSM IA 50314 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-08 Maya Bromolson maya@goodvibesmovement.org Des Moines IA United States Joel Donaghy Brian Donaghy Signed (1) The employer does not elect the employers’ liability coverage. Maya Bromolson maya@goodvibesmovement.org Executive Director Des Moines IA United States Joel Donaghy Brian Donaghy Signed
569 2021-07-09 12:18 Anonymous (not verified) 173.17.250.209 Forest Ave Outreach dba Good Vibes Movement Limited Liability Company 1600 6th Ave DSM IA 50314 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-09 Ben Spellman ben@goodvibesmovement.org Des Moines IA United States Joel Donaghy Brian Donaghy Signed (1) The employer does not elect the employers’ liability coverage. Maya Bromolson maya@goodvibesmovement.org Executive Director Des Moines IA United States Joel Donaghy Brian Donaghy Signed
350 2021-01-04 09:35 Anonymous (not verified) 173.29.234.11 Plum Communications, LLC Limited Liability Company 1018 NW Campus Ridge CT, Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-01 Brian Shearer brian@plumllc.com Ankeny Polk IA Brian Shearer Brian Shearer Signed (1) The employer does not elect the employers’ liability coverage. Brian Shearer brian@plumllc.com Owner Ankeny Polk IA Brian Shearer Brian Shearer Signed
823 2022-01-05 16:35 Anonymous (not verified) 173.29.232.165 Plum Communications, LLC Limited Liability Company 1018 NW Campus Ridge CT, Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Brian Shearer brian@plumllc.com Ankeny Polk Iowa Brian Shearer Brian Shearer Signed (1) The employer does not elect the employers’ liability coverage. Brian Shearer brian@plumllc.com Owner Ankeny Polk IA Brian Shearer Brian Shearer Signed
641 2021-09-17 09:16 Anonymous (not verified) 72.255.121.118 Osman Gonzalez-Sarceno Proprietorship 1403 Aspen Dr Adel, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-17 Osman Gonzalez-Sarceno workorders@shoproyalflooring.com Des Moines Polk IA Melissa Bolanos Brianna Fuller Signed (1) The employer does not elect the employers’ liability coverage. Osman Gonzalez-Sarceno workorders@shoproyalflooring.com Owner Des Moines Polk Iowa Melissa Bolanos Brianna Fuller Signed
1549 2023-03-30 14:22 Anonymous (not verified) 94.188.205.166 BILL MASSENGALE TRUCKING LLC Limited Liability Company 4583 100TH 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. 2023-03-30 WILLIAM MASSENGALE BLMASSE31@GMAIL.COM MONTEZUMA Iowa United States Lori Massengale Brianna Massengale Signed (1) The employer does not elect the employers’ liability coverage. Lori MASSENGALE BLMASSE31@GMAIL.COM Spouse MONTEZUMA Iowa United States WILLIAM MASSENGALE Brianna MASSENGALE Signed
1604 2023-04-26 09:03 Anonymous (not verified) 94.188.207.225 LeafHome Solutions LLC Limited Liability Company 3060 SE Grimes Boulevard Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Braedyn Baylor bbaylor66@gmail.com West des moines Polk Iowa Cassidy Tolle Jeffrey Baylor Signed (1) The employer does not elect the employers’ liability coverage. Braedyn Baylor bbaylor66@gmail.com Self West Des Moines Polk Iowa Julie Baylor Brianna Stephens Signed
251 2020-09-08 17:00 Anonymous (not verified) 173.27.45.95 Peerless Construction, LLC Limited Liability Company 4718 E 49th Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-08 Grant Jipp grant.peerless@gmail.com Davenport Scott Iowa Dan Knight Bridget Knight Signed (1) The employer does not elect the employers’ liability coverage. Grant Jipp grant.peerless@gmail.com Owner Davenport Scott Iowa Dan Knight Bridget Knight Signed
117 2020-04-11 09:08 Anonymous (not verified) 72.255.83.134 MIDWEST AG SOLUTIONS, LLC Limited Liability Company 4949 PLEASANT ST, STE 204, WEST DES MOINES, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-11 DALE A EASTMAN dale@emdsm.com Waukee Dallas IA Gary Marshall Brittain Bachus Signed (1) The employer does not elect the employers’ liability coverage. DALE A EASTMAN dale@emdsm.com same WAUKEE DALLAS IA GARY MARSHALL BRITTAIN BACHUS Signed
28 2020-01-06 13:39 Anonymous (not verified) 108.178.203.226 MULLIS CATTLE LLC Limited Liability Company 2506 155TH ST, EARLVILLE IA 52041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 NICOLAS MULLIS JAMES@CIOIA.COM GREELEY DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed (1) The employer does not elect the employers’ liability coverage. NICOLAS MULLIS JAMES@CIOIA.COM OWNER GREELEY DELAWARE IA MERRI MOSER BRITTANY LANSING Signed
29 2020-01-06 13:44 Anonymous (not verified) 108.178.203.226 MULLIS CATTLE LLC Limited Liability Company 2506 155TH ST, EARLVILLE IA 52041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 DAVID MULLIS JAMES@CIOIA.COM EARLVILLE DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed (1) The employer does not elect the employers’ liability coverage. DAVID MULLIS JAMES@CIOIA.COM OWNER EARLVILLE DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed
2037 2024-02-07 22:06 Anonymous (not verified) 94.188.205.174 Harold wotton snow and lawn service Proprietorship 117 east kimball st hancock Iowa 51536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-04 Harold wotton hwotton79@icloud.com Hancock Iowa United States Iowa Crystal Wogomon Brody Weber Signed (1) The employer does not elect the employers’ liability coverage. Harold wotton hwotton79@icloud.com Owner Hancock United States Iowa Crystal Wogomon Brody Weber Signed
704 2021-11-01 18:43 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Limited Liability Company 204 Oak Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-30 Armin Harold Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed (1) The employer does not elect the employers’ liability coverage. Armin Harold Martin arminbonnie@aol.com self Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed
1550 2023-03-31 13:35 Anonymous (not verified) 94.188.205.177 Nadarevic Group LLC Limited Liability Company 3633 NW 177th Ct, 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. 2023-03-31 Ajdin Nadarevic ajdin@silverstonedevgroup.com Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed (1) The employer does not elect the employers’ liability coverage. Ajdin Nadarevic ajdin@silverstonedevgroup.com Owner Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed
1551 2023-03-31 13:37 Anonymous (not verified) 94.188.205.176 Nadarevic Group LLC Limited Liability Company 3633 NW 177th Ct, 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. 2023-03-31 Nicole Nadarevic niki@silverstonedevgroup.com Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed (1) The employer does not elect the employers’ liability coverage. Ajdin Nadarevic ajdin@silverstonedevgroup.com Owner Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed
684 2021-10-20 13:25 Anonymous (not verified) 65.144.174.26 A and H Home Improvement Limited Liability Company 600 NE 64th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-20 Ivan A. Abel aandhhomeimprovement@gmail.com Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed (1) The employer does not elect the employers’ liability coverage. Ivan A. Abel aandhhomeimprovement@gmail.com Self Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed
1437 2023-02-01 15:42 Anonymous (not verified) 174.215.242.112 Safe step walk in tub of Minnesota Limited Liability Company 7300 Washington Ave S. Eden prairie, MN 55344 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-01 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. James alley JAlley@safesteptub.com Vice president of production Eden prairie Hennepin MN Brent Jarvis Bruce illies Signed
248 2020-08-27 16:01 Anonymous (not verified) 142.202.101.194 Nathan Unruh Construction Proprietorship P.O. Box 181 Mechanicsville, IA. 52306 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-27 Nathan Unruh Nathanunruh@gmail.com Mechanicsville Cedar Iowa Randy Rouse Bruce Seehusen Signed (1) The employer does not elect the employers’ liability coverage. Nathan Unruh nathanunruh@gmail.com Same person Mechanicsville Cedar Iowa Randy Rouse Bruce Seehusen Signed
2074 2024-03-04 16:56 Anonymous (not verified) 94.188.207.224 IG painting Llc Limited Liability Company 416 51st ST West des moines,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. 2024-03-01 antonio J Iglesias antonio_joserene@hotmail.com west Des moines polk iowa Raul Gomez Bruno Cruz Signed (1) The employer does not elect the employers’ liability coverage. Antonio J Iglesias antonio_joserene@hotmail.com not relationship West des Moines polk iowa Raul Gomez Bruno cruz Signed
1329 2022-10-10 10:55 Anonymous (not verified) 173.25.222.69 Eli's Limited Liability Company 931 S Van Buren St Iowa City, Iowa 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-10 Elijah Ortiz eortiz15@gmail.com Iowa City Johnson Iowa Erica Mason Bryan Horrell Signed (1) The employer does not elect the employers’ liability coverage. Elijah Ortiz eortiz15@gmail.com Proprietor Iowa City Johnson Iowa Erica Mason Bryan Horrell Signed
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
2044 2024-02-15 09:52 Anonymous (not verified) 94.188.205.168 Messenger Trucking LLC Limited Liability Company 1869 255th St., Fairfield, IA 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-08 Timothy Duncan Messenger tmessengertrucking@gmail.com Fairfield Jefferson Iowa Casey Messenger Bud Smith Signed (1) The employer does not elect the employers’ liability coverage. Timothy Duncan Messenger tmessengertrucking@gmail.com Self Fairfield Jefferson Iowa Casey Messenger Bud Smith Signed
882 2022-02-02 11:09 Anonymous (not verified) 67.55.205.135 Tree & Forestry Equipment Partnership 201 Deer Haven St., 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. (1) I am not electing the employers’ liability coverage. 2022-02-02 Jennifer Hicks jennifer@treeandforestry.com Gowrie Webster Iowa Chad Hicks Caden Konecne Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Hicks jennifer@treeandforestry.com self Gowrie Webster Iowa Chad Hicks Caden Konecne Signed
156 2020-05-13 20:37 Anonymous (not verified) 216.106.236.82 MR Electric LLC Limited Liability Company 1853 230st Inwood, IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-13 Matthew Rozeboom matt.rozeboom@gmail.com Inwood Lyon Iowa Rachel Schruers Caitlin Fluit Signed (1) The employer does not elect the employers’ liability coverage. Matt Rozeboom matt.rozeboom@gmail.com Owner/President Inwood Lyon Iowa Rachel Schruers Caitlin Fluit Signed
1448 2023-02-10 16:55 Anonymous (not verified) 94.188.205.177 Marks Nursery LLC Limited Liability Company 15008 310th Trl, Redfield, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-10 Susan L Jones sljoines026@gmail.com Redfield Dallas Iowa Douglas Jones Caitlin Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Donald Richardson DonR@phillipsassociatesins.net Agent Redfield Dallas Iowa Douglas Zimmerman Caitlin Zimmerman Signed
1423 2023-01-16 14:03 Anonymous (not verified) 173.224.19.200 Hoofin-It Proprietorship 86148 537th Ave. Plainview, NE 68769 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-16 Chase Terrill terrill365@gmail.com Pierce Pierce Nebraska Jim Aschoff Calan List Signed (1) The employer does not elect the employers’ liability coverage. Cole Aschoff aschoff_2@icloud.com Co-Owner Plainview Pierce Nebraska Jim Aschoff Calan List Signed
1091 2022-05-06 09:54 Anonymous (not verified) 97.127.228.168 American Concrete Proprietorship 2629 Sheffield dr. Davenport iowa 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Craig wells craiglwells@hotmail.com Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed (1) The employer does not elect the employers’ liability coverage. DK home products anne@dkhomeproducts.com Sub contractor Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed
1430 2023-01-25 14:50 Anonymous (not verified) 104.222.82.50 Pille Ceramic Tile Proprietorship 17645 Guthrie 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. 2023-01-25 Bernie Pille blpille@yahoo.com Maple River Carroll IA Lisa Pille None Signed (1) The employer does not elect the employers’ liability coverage. Bernie Pille blpille@yahoo.com Self Maple River Carroll IA Lisa Pille Cameron Pille Signed
1886 2023-10-31 15:53 Anonymous (not verified) 94.188.205.176 CEM Businesses LLC Limited Liability Company 608 Evergreen Cir Nw Bondurant, IA 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-31 Dane McDonald dane.mcdonald@stellar-solar.net Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
1887 2023-10-31 15:57 Anonymous (not verified) 94.188.207.227 CEM BUSINESSES LLC Limited Liability Company 608 evergreen cir nw Bondurant, IA 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-31 Dustin Rudolph dmrudo@gmail.com Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
1888 2023-10-31 15:59 Anonymous (not verified) 94.188.207.225 CEM Businesses LLC Limited Liability Company 608 Evergreen Cir 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. 2023-10-31 Ryan Canales ryancanales44@gmail.com West Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
90 2020-03-13 15:44 Anonymous (not verified) 173.24.190.134 Heath Householder Limited Liability Company 2 N Huron Street, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-07 Heath Householder heath679@live.com Emmetsburg Palo Alto Iowa Scott Wirtz Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Heath Householder heath679@live.com Member of LLC Emmetsburg Palo Alto Iowa Scott Wirtz Candie Clark Signed
91 2020-03-13 15:51 Anonymous (not verified) 173.24.190.134 Small Town RV, LLC Limited Liability Company 112 Miller 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. 2020-03-09 Heath Sabin sales@smalltownrv.com Mallard Palo Alto Iowa Dave Walters Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Heath Sabin sales@smalltownrv.com Member of LLC Mallard Palo Alto Iowa Dave Walters Candie Clark Signed
92 2020-03-13 15:53 Anonymous (not verified) 173.24.190.134 Tammy Sabin Limited Liability Company 112 Miller 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. 2020-03-09 Tammy Sabin sales@smalltownrv.com Mallard Palo Alto Iowa Dave Walters Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Tammy Sabin sales@smalltownrv.com Member of LLC Mallard Palo Alto Iowa Dave Walters Candie Clark Signed
411 2021-02-22 15:58 Anonymous (not verified) 173.24.190.134 The Willow Tree Garden Center Limited Liability Company 2103 19rh Street, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-22 Erica Janssen mrjanz13@gmail.com Emmetsburg Palo Alto Iowa Marilee Lace Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Erica Janssen mrjanz13@gmail.com Member of LLC Emmetsburg Palo Alto Iowa Marilee Lace Candie Clark Signed
2170 2024-04-22 10:11 Anonymous (not verified) 94.188.207.224 Joy Ride Transport Limited Liability Company 3105 SE Miehe Drive, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Ted Cochran ted@ridejoyride.com Clive Dallas IA Lindsey Pace Carissa Gehrking Signed (1) The employer does not elect the employers’ liability coverage. Ted Cochran ted@ridejoyride.com Self Clive Dallas IA Lindsey Pace Carissa Gehrking 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
1146 2022-06-07 11:51 Anonymous (not verified) 173.27.226.177 Evans Endeavors LLC Limited Liability Company 513 N Roche St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-07 Cody Evans evansendeavor@gmail.com Knoxville Marion Iowa Erin Six Carl stoffer Signed (1) The employer does not elect the employers’ liability coverage. Cody Evans evansendeavor@gmail.com Myself Knoxville Marion Iowa Erin six Carl Stoffer Signed
239 2020-08-20 14:47 Anonymous (not verified) 173.23.150.218 Gaytan Framing LLC Limited Liability Company 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. 2020-08-20 Jose Gaytan jose1988.jg8@gmail.com Des Moines Polk Iowa Misael Balleza Carla Gaytan Signed (1) The employer does not elect the employers’ liability coverage. Jose Gaytan Ruiz jose1988.jg8@gmail.com self Des Moines Polk Iowa Misael Balleza Carla Gaytan Signed
619 2021-08-25 14:31 Anonymous (not verified) 192.154.15.2 MAV Restorations LLC Limited Liability Company 5461 Meadow Ct, Asbury, IA 52002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-25 Matthew Vaske mlvaske@gmail.com Asbury Dubuque IA Randi Taylor Carla Martin Signed (1) The employer does not elect the employers’ liability coverage. Matthew Vaske mlvaske@gmail.com Self Asbury Dubuque IA Randi Taylor Carla Martin Signed
1898 2023-11-09 09:56 Anonymous (not verified) 94.188.207.227 RC Restoration LLC Limited Liability Company 991 June Drive, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-09 Luke Hoffmann luke@rentcube.com Dubuque Dubuque Iowa Randi Taylor Carla Martin Signed (1) The employer does not elect the employers’ liability coverage. Luke Hoffman luke@rentcube.com Owner Dubuque Dubuque IA Randi Taylor Carla Martin Signed
1905 2023-11-13 21:35 Anonymous (not verified) 94.188.205.167 Bartolo Lopez Limited Liability Company 2404 cass st Fort Worth tx 76112 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-13 Bartolo Lopez bartololopez3737@gmail.com Fort Worth tx Tarrant county Tx Airan Zamudio Carlos Lopez Signed (1) The employer does not elect the employers’ liability coverage. Bartolo Lopez bartololopez3737@mail.com Boss of the company Fort Worth Tarrant county Texas Airan Zamudio Carlos lopez Signed
338 2020-12-13 16:31 Anonymous (not verified) 107.77.161.48 LAVH LLC Limited Liability Company 1520 E Pleasant View Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-13 Luis Vasquez vasquezluis239@gmail.com Des Moines Polk Iowa Lorena Aguilar Carlos Mendoza Signed (1) The employer does not elect the employers’ liability coverage. LAVH LLC vasquezluis239@gmail.com Owner Des Moines Polk Iowa Lorena Aguilar Carlos Mendoza Signed
873 2022-01-30 18:57 Anonymous (not verified) 75.162.11.91 Iowa Carpentry Construction Limited Liability Company 3000 University Ave West Des Moines,IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Martha Marca Iowacarpentryconstruction@gmail.com Urbandale Polk Iowa Martha Marca Carlos Velazquez Signed (1) The employer does not elect the employers’ liability coverage. Emily Segura iowacarpentryconstrucion@gmail.com Worker West Des Moines Polk Iowa Martha Marca Carlos Velazquez 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
468 2021-04-12 14:54 Anonymous (not verified) 173.27.224.230 PCI Turf LLC Limited Liability Company 1313 N Grant St. Knoxville, IA 50138 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-12 Ryan Trout rtrout22@yahoo.com Knoxville Marion Iowa Joseph Durham Carson Peterson Signed (1) The employer does not elect the employers’ liability coverage. Ryan Trout pci.turf@yahoo.com Self- owner/operator Knoxville Marion Iowa Joseph Durham Carson Peterson Signed
331 2020-12-03 10:19 Anonymous (not verified) 174.213.165.124 TTC Cleaning Services Limited Liability Company 2155-230th St Marshalltown, IA. 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. 2020-12-03 Zachary Stephen Bolar zbolar80@gmail.com Marshalltown Marshall IA Brian Mason Casey Jesina Signed (1) The employer does not elect the employers’ liability coverage. Zachary Stephen Bolar zbolar80@gmail.com Self Marshall Marshall IA Brian Mason Casey Jesina Signed
38 2020-01-18 12:15 Anonymous (not verified) 206.109.174.199 BJS Frenchies, LLC Limited Liability Company 20081 Highway J 46 Centerville Iowa 52544 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 J. Jamie Tracy jamiespuppies@yahoo.com Centerville Appanoose Iowa Misty O'Hair Casey Leach Signed (1) The employer does not elect the employers’ liability coverage. Bruce E Tracy jamiespuppies@yahoo.com Husband and Co Owner Centerville Appanoose Iowa Misty O'Hair Casey Leach Signed
174 2020-06-05 15:10 Anonymous (not verified) 98.21.202.208 Bloomfield Properties LLC Limited Liability Company 206 Weaver Road, Bloomfield, IA 52537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-05 Terri Roberts terri_roberts58@yahoo.com Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed (1) The employer does not elect the employers’ liability coverage. Terri Roberts terri_roberts58@yahoo.com shareholder Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed
175 2020-06-05 15:14 Anonymous (not verified) 98.21.202.208 Bloomfield Properties LLC Limited Liability Company 206 Weaver Road, Bloomfield, IA 52537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-05 Dave Lawrence terri_roberts58@yahoo.com Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed (1) The employer does not elect the employers’ liability coverage. Terri Roberts terri_roberts58@yahoo.com shareholder Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed
1781 2023-08-03 21:23 Anonymous (not verified) 94.188.205.166 Ron Peiffer Machine Limited Liability Company 139 S 1st St Harpers Ferry, Ia 52146 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Ron Peiffer ron@rpeiffer.com Harpers Ferry Allamakee Iowa Marie Burington Cassie Bakke Signed (1) The employer does not elect the employers’ liability coverage. Ron Peiffer ron@rpeiffer.com myself- SOLE PROPRIETOR Harpers Ferry Allamakee Iowa Marie Burington Cassie Bakke Signed
1999 2024-01-25 16:57 Anonymous (not verified) 94.188.205.177 Nicholas Schaff Limited Liability Company 6934 rolling ridge ct sw cedar rapids Iowa 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-25 Nicholas Schaff schaff.lawncare@gmail.com cedar rapids linn iowa Brian Zeller Cassie Schaff Signed (1) The employer does not elect the employers’ liability coverage. Nicholas schaff schaff.lawncare@gmail.com Same person cedar rapids iowa iowa Brian zeller cassie schaff Signed
983 2022-03-18 11:02 Anonymous (not verified) 66.180.9.84 Gary Runyon Proprietorship 101 Harris St Ste 1 Hastings, IA 51540 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Gary Runyon garyrunyon26@gmail.com Henderson Mills Iowa Gary Runyon Cathy Mardesen Signed (1) The employer does not elect the employers’ liability coverage. Gary Runyon garyrunyon26@gmail.com owner Henderson Mills Iowa Gary Runyon Cathy Mardesen Signed
919 2022-02-16 21:13 Anonymous (not verified) 208.126.203.31 K & D Land Improvement, LLC Limited Liability Company 2719 270th Street, Lehigh, Iowa 50557 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-16 Daniel Hansen dhansen@lvcta.com Lehigh Webster Iowa Karen Hansen Cathy Mickelson Signed (1) The employer does not elect the employers’ liability coverage. Daniel Hansen dhansen@lvcta.com Member Lehigh Webster Iowa Karen Hansen Cathy Mickelson Signed
447 2021-03-24 14:09 Anonymous (not verified) 208.90.15.53 Gabe Saenz, LLC Limited Liability Company PO Box 53 Humboldt, IA 50548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-24 Gabriel Saenz gsaenzh@gmail.com Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed (1) The employer does not elect the employers’ liability coverage. Gabriel Saenz gsaenzh@gmail.com Owner Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed
70 2020-02-19 19:30 Anonymous (not verified) 173.25.39.58 Central Iowa Portable Welding Limited Liability Company 708 S Main St. Woodward Ia, 50276 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-19 Eric Lendt Eric@weldiowa.com Woodward America IA Chris Lendt Central Iowa Portable Welding Signed (1) The employer does not elect the employers’ liability coverage. Central Iowa Portable Welding Eric@weldiowa.com Himself woodward American IA Central Iowa Portable Welding Central Iowa Portable Welding Signed
1252 2022-08-12 13:11 Anonymous (not verified) 166.181.85.235 Cesar cardenas Proprietorship 48644 roma valley 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. 2022-06-06 Cesar Octavio Cardenas navarrete cesarcardenas981@gmail.com Des moines Polk Iowa Cesar cardenas navarrete Cesar cardenas Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Cesar cardenas cesarcardenas981@gmail.com Myself Des moines Polk Iowa Cesar cardenas Cesar cardenas gonzalez Signed
1602 2023-04-25 20:10 Anonymous (not verified) 94.188.207.228 Miguel D. Limited Liability Company 1221 22nd st des moines ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-21 Miguel Duron Duron6478@gmail.com Des moines Polk Ia Uziel martinez Cesar jaz Signed (1) The employer does not elect the employers’ liability coverage. Miguel Duron Diron6478@gmail.com Self Des moines Polk Iowa Uziel Martinez Cesar jaz Signed
551 2021-06-29 09:18 Anonymous (not verified) 72.168.160.90 BERNARD WATERBECK Limited Liability Company 1353 280TH STREET, GARWIN, IOWA 50632 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-29 BERNARD WATERBECK garwinacres2012@hotmail.com GARWIN TAMA IOWA DEAN KELLER CESAR MARROQUIN Signed (1) The employer does not elect the employers’ liability coverage. BERNARD WATERBECK garwinacres2012@hotmail.com SAME PERSON GARWIN TAMA IOWA DEAN KELLER CESAR MARROQUIN 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
1445 2023-02-08 14:56 Anonymous (not verified) 94.188.207.225 Spencer Imaging Center, LLC Limited Liability Company 710 S. Grand 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. 2023-02-08 William Jay Muller mullerwilliam@hotmail.com Spencer Clay IA Shanna Marie Kooker Chad A Roemeling Signed (1) The employer does not elect the employers’ liability coverage. Alexander Pruitt apruitt@ncn.net Partner Spencer Clay IA Shanna Marie Kooker Chad A Roemeling Signed
286 2020-10-21 18:32 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Daniel Bilyeu danielbilyeu@gmail.com Nixa Christian Missouri Gary George Bilyeu Chad Anthony Charles Signed (1) The employer does not elect the employers’ liability coverage. Daniel Bilyeu danielbilyeu@gmail.com Owner Nixa Christian Missouri Gary George Bilyeu Chad Anthony Charles Signed
525 2021-05-18 09:42 Anonymous (not verified) 50.82.130.211 Adrian Bernard Proprietorship 803 Russell Circle, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-07 Adrian Bernard cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Adrian Bernard cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Chad Campbell Signed
1787 2023-08-07 13:15 Anonymous (not verified) 94.188.205.177 Dryseal Roofing and Construction Proprietorship 390 olive st. Martensdale, Iowa 50160 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Travis w. Tibbits travistibbits@yahoo.com Martensdake Warren Iowa Dawn Marie tibbits Chad David walker Signed (1) The employer does not elect the employers’ liability coverage. Travis Wayne Tibbits travistibbits@yahoo.com Self Martensdale Warren Iowa Dawn Marie Tibbits Chad David walker Signed
1555 2023-04-05 08:03 Anonymous (not verified) 94.188.207.227 DK Motor Freight Proprietorship 3621 Tyler 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. 2023-04-05 David Kirchner dkirchner89@gmail.com Hartley Obrien Iowa Janna VanDonge Chad Driesen Signed (1) The employer does not elect the employers’ liability coverage. David Kirchner dkirchner89@gmail.com Self Hartley Iowa United States Janna VanDonge Chad Driesen Signed
2056 2024-02-24 08:17 Anonymous (not verified) 94.188.207.230 C&C Property LLC Limited Liability Partnership PO Box 418 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-24 Joshua Darwin Wessel wesselclublambs@gmail.com Kiron Crawford IA Chad D Foust Chad A Tweeten Signed (1) The employer does not elect the employers’ liability coverage. Chad Tweeten tweeten@hotmail.com Barn Manager 1099 employee Eagle grove Wright Iowa Chad Tweeten Chad Foust Signed
1652 2023-05-17 20:44 Anonymous (not verified) 94.188.205.167 Fox Trucking Proprietorship 2774 March Ave Greene Ia. 50636 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-17 Chet D. Fox cjakfox@yahoo.com Greene Floyd Iowa Jack Dwyer Chad Olson Signed (1) The employer does not elect the employers’ liability coverage. Chet Fox cjakfox@yahoo.com myself Greene Floyd Iowa Jack Dwyer Chad Olson Signed
1454 2023-02-14 09:34 Anonymous (not verified) 94.188.207.227 Spencer Imaging Center, LLC Limited Liability Company 710 S. Grand Ave., Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-14 Alexander Pruitt apruitt@ncn.net Spencer Clay IA Shanna Marie Kooker Chad Roemeling Signed (1) The employer does not elect the employers’ liability coverage. William Muller mullerwilliam@hotmail.com Co owner Spencer Clay IA Shanna Marie Kooker Chad Roemeling Signed
1120 2022-05-19 09:49 Anonymous (not verified) 65.125.92.130 JG Landscaping, LLC Limited Liability Company 317 E 23rd St. Des Moines, IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-19 Javier Alexander Guzman alexguz76@outlook.com Des Moines Polk IA Brenda Reedy Chad Smith Signed (1) The employer does not elect the employers’ liability coverage. Javier Alexander Guzman alexguz76@outlook.com Self Des Moines Polk IA Brenda Reedy Chad Smith Signed
433 2021-03-12 20:47 Anonymous (not verified) 173.28.1.65 HomeTeam painting llc Limited Liability Company 3810 Amherst Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-12 Johnny ollin johnnyollin@gmail.com DesMoines Polk IOWA David Carney Chad Winslow Signed (1) The employer does not elect the employers’ liability coverage. Johnny ollin johnnyollin@gmail.com Myself DesMoines Polk IOWA David Carney Chad Winslow Signed
1612 2023-04-27 10:37 Anonymous (not verified) 94.188.207.223 Grind Works LLC Proprietorship 26416 289th place Unit H Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-27 Adam Samuelson Hello@grindworksia.com Adel Dallas Iowa Chandler Clark Adam Samuelson Signed (1) The employer does not elect the employers’ liability coverage. Adam Samuelson Hello@Grindowrksia.com N/A Adel Dallas Iowa Adam Samuelson Chandler Clark 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
937 2022-02-25 11:55 Anonymous (not verified) 174.242.226.43 K3 Recycling Limited Liability Company 510 West 2nd 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. 2022-02-25 Justin Kappelman justin@kappelmanappliance.com Indianola Iowa Iowa Kristy Kappelman Charles Kappelman Signed (1) The employer does not elect the employers’ liability coverage. Justin Kappelman justin@kappelmanappliance.com Same Indianola Iowa Iowa Kristy Kappelman Charles Kappelman Signed
994 2022-03-22 12:19 Anonymous (not verified) 75.162.125.176 performance painting llc Limited Liability Company 4905 nw 4th street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-22 thomas lilly TLilly816@aol.com ankeny IOWA United States Sharon kay Gaulke Charles Thomas Cater Signed (1) The employer does not elect the employers’ liability coverage. Performance Painting LLC TLilly816@aol.com owner ankeny IOWA United States Sharon Kay Gaulke Charles Thomas Cater Signed
1169 2022-06-23 16:23 Anonymous (not verified) 159.45.71.17 Whitlow Remodeling and Home Services, LLC Limited Liability Company 6421 NW 54th Ct Johnston Iowa 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 Scot Alan Whitlow resaw375@msn.com Johnston Polk Iowa Erin Scanlan Charles Thorn Signed (1) The employer does not elect the employers’ liability coverage. Scot Alan Whitlow resaw375@msn.com Owner Johnston Polk Iowa Erin Scanlan Charles Thorn Signed
1629 2023-05-09 08:50 Anonymous (not verified) 94.188.207.223 Alex Jones Proprietorship 2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-09 Alex Jones ajones0425@yahoo.com Cedar Rapids Linn Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Charles Wood Signed
1828 2023-09-06 14:43 Anonymous (not verified) 94.188.205.177 Des Moines Smart Solutions LLC. Proprietorship 1329 56th st, Des Moines, IA 50311, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-06 Denzel Colocho alejandro_colcho@yahoo.com Des Moines, IA Polk Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay MO Jordan Loyd Charles Wood Signed
1857 2023-10-02 16:33 Anonymous (not verified) 94.188.205.169 Noah Blount Proprietorship 2611 capitol ave, Des Moines, IA 50317, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-02 Noah Blount nbeav5@gmail.com Des Moines Des Moines Iowa Jordan Loyd Charles Woods Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Jackson Missouri Jordan Loyd Charles Woods Signed
1195 2022-07-08 13:24 Anonymous (not verified) 174.198.67.66 Chapas Construction Limited Liability Company 6424 Roseland 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. 2022-07-08 Polibio Raul Chapa Farez chapasconstructionllc@gmail.com Urbandale IA IA Brenda Rivas Charlie Chapa Signed (1) The employer does not elect the employers’ liability coverage. Polibio Raul Chapa chapasconstructionllc@gmail.com President Urbandale IA IA Brenda Rivas Charlie Chapa Signed
481 2021-04-14 17:15 Anonymous (not verified) 199.66.15.81 K3 Recycling Limited Liability Company 601 W. 1st Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-14 JUSTIN KAPPELMAN justin@kappelmanappliance.com Indianola Iowa Iowa Kristy Kappelman Charlie Kappelman Signed (1) The employer does not elect the employers’ liability coverage. JUSTIN KAPPELMAN justin@kappelmanappliance.com Same person Indianola IA IA Kristy Kappelman Charlie Kappelman Signed
1562 2023-04-10 07:43 Anonymous (not verified) 94.188.205.174 JB Concrete and Construction Limited Liability Company 306 1st Ave N.W Dayton 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. 2023-04-10 JaredBerglund jaredberglund71@gmail.com Dayton Webster Iowa Travis Sonksen Chase Haman Signed (1) The employer does not elect the employers’ liability coverage. JaredBerglund jaredberglund71@gmail.com Owner Dayton Webster Iowa Travis Sonksen Chase Haman Signed
209 2020-07-19 17:02 Anonymous (not verified) 173.189.166.183 Merle Fox Proprietorship 314 N Jackson St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-19 Merle T Fox merletravisfox.79@gmail.com Lisbon Linn Iowa Dustin Ohlfest Chelsea Brown Signed (1) The employer does not elect the employers’ liability coverage. Merle Fox merletravisfox.79@gmail.com self Lisbon Linn Iowa Dustin Ohlfest Chelsea Brown Signed
176 2020-06-07 08:23 Anonymous (not verified) 174.16.51.128 TrueFood LLC Limited Liability Company 2055 Nature Ave Stanton IA 51573 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 Brian Barkman brian.barkman@truefood.farm Georgetown Williamson Texas Wanda Barkman Chelsea Church Signed (1) The employer does not elect the employers’ liability coverage. Brian Barkman brian.barkman@truefood.farm TrueFood LLC is owned by agent Stanton Montgomery IA Wanda Barkman Chelsea Church Signed
135 2020-04-28 10:04 Anonymous (not verified) 74.84.101.138 W.A.D.E., Inc. DBA Decorah Cleaners Proprietorship 504 Heivly Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Darrin Walter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed (1) The employer does not elect the employers’ liability coverage. Darrin Walter chelsea.whalen@upperiowains.com Owner Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed
136 2020-04-28 10:06 Anonymous (not verified) 74.84.101.138 W. A. D. E., Inc. DBA Decorah Cleaners Proprietorship 504 Heivly Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Wanda Walter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed (1) The employer does not elect the employers’ liability coverage. Wanda Walter chelsea.whalen@upperiowains.com Owner Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed
158 2020-05-18 13:58 Anonymous (not verified) 108.59.100.21 LNM Truck & Trailer Repair LLC Limited Liability Company 902 Rossville Rd, Waukon, IA 52172 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-05-18 Matthew Hawkins lnmtruckandtrailerrepair@gmail.com Waterville Allamakee IA Jane M Regan Chelsea Whalen Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Matthew Hawkins lnmtruckandtrailerrepair@gmail.com Owner Waterville Allamakee IA Jane M Regan Chelsea Whalen Signed
905 2022-02-08 10:23 Anonymous (not verified) 74.115.101.41 Triple TTT Transport, LLC Limited Liability Company 307 7th Avenue SE, Belmond, IA 50541 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-08 Clint C Christians christiansclint0@gmail.com Pocahontas pocahontas Iowa Dale R Eng Cheri Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Clint Christians christiansclint0@gmail.com Partner Pocahontas Pocahontas Iowa Dale Eng Cheri Zimmerman Signed
963 2022-03-10 10:51 Anonymous (not verified) 173.29.157.192 Thompson Servcies LLC Limited Liability Company 21105 N Brady St., Davenport, IA 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-10 Daniel M Konrardy dkonrardy64@yahoo.com Davenport Scott Iowa David Konrardy Cheryl Thompson Signed (1) The employer does not elect the employers’ liability coverage. Daniel M Konrardy dkonrardy64@yahoo.com LLC member/partner Davenport Scott Iowa David Konrardy Cheryl Thompson Signed
595 2021-08-03 13:53 Anonymous (not verified) 174.248.224.252 Joseph r cunningham dba freedom field services Proprietorship 6285 n 67th ave w Baxter iowa 50028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-03 Joseph r Cunningham jr. joecunningham1966@protonmail.com Baxter Jasper Iowa Chelsey Cunningham Chris Cort Signed (1) The employer does not elect the employers’ liability coverage. Joseph r cunningham jr joecunningham1966@protonmail.com Me Baxter Jasper Iowa Chelsey cunningham Chris cort Signed
275 2020-10-08 11:56 Anonymous (not verified) 166.224.213.71 Michael corcoran Proprietorship 311 e elm st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-07 Michael corcoran mikecorcoran1990@gmail.com West Union Fayette IA Heather corcoran Chris Fels Signed (1) The employer does not elect the employers’ liability coverage. Michael corcoran mikecorcoran1990@gmail.com Self West Union Fayette IA Heather corcoran Chris fels Signed
25 2020-01-03 13:09 Anonymous (not verified) 74.84.121.206 Raymond Jones Proprietorship P O Box 682 Monona IA 52159 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-29 Raymond Jones darrele@ciains.biz Monona Clayton Iowa Darrel J Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel J Elsbernd darrele@ciains.biz insurance agent Lime Springs Howard Iowa Darrel J Elsbernd Chris Fye Signed
34 2020-01-10 15:56 Anonymous (not verified) 74.84.121.206 Milferd Loewen Proprietorship 6568 Hwy 63, Lime Springs, IA 52155 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-10 Milferd Loewen darrele@ciains.biz Lime Springs Howard Iowa Darrel J. Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Milferd Loewen darrele@ciains.biz self Lime Springs Howard Iowa Darrel J. Elsbernd Chris Fye Signed
1472 2023-02-20 15:52 Anonymous (not verified) 94.188.207.230 C & A Fox Farms LLC Limited Liability Company 3275 Valley Ave Orchard IA 50460 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Curtis Fox sales@foxfarmsllc.com Orchard IOWA United States Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Curtis Fox sales@foxfarmsllc.com Self Orchard IOWA United States Darrel Elsbernd Chris Fye Signed
1473 2023-02-20 15:57 Anonymous (not verified) 94.188.207.224 C & A Fox Farms LLC Limited Liability Company 3275 valley Ave Orchard IA 50460 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Allen Fox sales@foxfarmsllc.com Orchard Mitchell Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Allen Fox sales@foxfarmsllc.com self Orchard Mitchell Iowa Darrel Elsbernd Chris Fye Signed
1499 2023-03-07 11:21 Anonymous (not verified) 94.188.205.177 Ryan Zimmerman Proprietorship 17606 35th St Lime Springs, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-27 Ryan Zimmerman darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed
1501 2023-03-07 11:27 Anonymous (not verified) 94.188.205.167 Adriene Dangler Proprietorship 2400 South Shore Dr Clear Lake, IA 50428 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Adrienne Dangler darrele@ciains.biz Clear Lake Cerro Gordo Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Clear Lake Cerro Gordo Iowa Darrel Elsbernd Chris Fye Signed
1503 2023-03-07 12:45 Anonymous (not verified) 94.188.205.177 Al's Roofing LLC Limited Liability Company P O Box 277 Lime Springs, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 John Martin darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Al's Roofing LLC darrele@ciains.biz agent Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed
879 2022-01-31 14:26 Anonymous (not verified) 173.27.146.201 Premier Window Cleaning LLC Limited Liability Company 420 E GRANGER 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. 2022-01-31 Frank Viola premierofiowa@gmail.com DES MOINES IA United States Ron Reynolds Chris Greco Signed (1) The employer does not elect the employers’ liability coverage. Frank Viola premierofiowa@gmail.com my self DES MOINES IA United States Ron Reynolds Chris Greco Signed
1636 2023-05-10 07:31 Anonymous (not verified) 94.188.205.167 Brad Bower Drywall LLC Limited Liability Company 209 Northridge 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. 2023-05-10 Bradley Bower bbower74@gmail.com West Branch Cedar Iowa Kirk Strunk Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Brad Bower bbower74@gmail.com Self West Branch Cedar Iowa Kirk Strunk Chris Hay Signed
1638 2023-05-11 07:33 Anonymous (not verified) 94.188.205.177 HV Drywall LLC Proprietorship 1991 Holiday Rd, Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-11 Jose Jesus Hernandez jh80292@gmail.com Coralville Johnson Iowa Arcel Servin Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Jose Jesus Hernandez jh80292@gmail.com self Coralville Johnson Iowa Arcel Servin Chris Hay Signed
1639 2023-05-11 07:39 Anonymous (not verified) 94.188.205.175 JYC Drywall LLC Proprietorship 1034 Grand Ave, Muscatine, IA 52761 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-11 Anastacio Zamarripa 1zama0081@gmail.com Muscatine Louisa Iowa Arcel Servin Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Anastacio Zamarripa 1zama0081@gmail.com Self Muscatine Louisa Iowa Arcel Servin Chris Hay Signed
1640 2023-05-11 07:42 Anonymous (not verified) 94.188.205.168 Ibarra Drywall LLC Proprietorship 1991 Holiday Rd, Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-11 Juan Reyes Ibarra juanreyes22031979@gmail.com Coralville Johnson Iowa Arcel Servin Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Juan Reyes Ibarra juanreyes22031979@gmail.com Self Coralville Johnson Iowa Arcel Servin Chris Hay Signed
1644 2023-05-12 07:59 Anonymous (not verified) 94.188.205.176 Blue Ribbon Drywall Proprietorship 3025 Peaceful Dr 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. 2023-05-12 Seth Mize Sr stmize@hotmail.com Riverside Washington Iowa Brad Bower Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Seth Mize Sr stmize@hotmail.com Self Riverside Washington Iowa Brad Bower Chris Hay Signed
1679 2023-06-06 08:27 Anonymous (not verified) 94.188.205.174 Remys Drywall LLC Proprietorship 42 Hoover Blvd 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. 2023-06-06 Remigio M Juan remmateojuan1997@gmail.com West Branch Cedar IA Brad Bower Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Remigio M Juan remmateojuan1997@gmail.com Self West Branch Cedar IA Brad Bower Chris Hay Signed
109 2020-04-03 12:42 Anonymous (not verified) 174.219.131.25 Upright Construction Limited Liability Company 2514 S norton ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-03 Maurice Williams uprightway@mail.com Sioux Falls Minihaha SD Ashley Williams Chris Johnson Signed (1) The employer does not elect the employers’ liability coverage. Maurice Williams uprightway@mail.com Owner Sioux Falls Minihaha SD Ashley Williams Chris Johnson Signed
1149 2022-06-09 17:43 Anonymous (not verified) 174.235.192.238 Bryan Linares Limited Liability Company 630 Hawthorne Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-09 Bryan Linares bryan.linares7798@gmail.com Crete Saline Nebraska Bryan Linares Chris Linares Signed (1) The employer does not elect the employers’ liability coverage. Christopher Linares chris5linares1995@gmail.com Brother Crete Saline Nebraska Bryan Linares Chris Linares Signed
1730 2023-07-09 23:39 Anonymous (not verified) 94.188.207.225 Steffens Constuction Proprietorship 68222 Lansing Road, Wiota, IA 50274 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-07 Bradyn Richard Steffens steffens4211@gmail.com Wiota Cass Iowa Katrina Sonntag Chris Obrien Signed (1) The employer does not elect the employers’ liability coverage. Audra Kelley Steffens steffens4211@gmail.com wife Wiota Cass Iowa Katrina Sonntag Chris Obrien Signed
1281 2022-08-24 11:06 Anonymous (not verified) 47.185.154.197 Zachary Bobo Proprietorship 2116 Newport Dr. Flower Mound, Tx. 75028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-24 Zachary Bobo ryan.zac@yahoo.com Flower Mound Denton Texas Kieth Volquardsen Chris Ventimiglia Signed (1) The employer does not elect the employers’ liability coverage. Zachary Bobo ryan.zac@yahoo.com Self Flower Mound Denton Texas Kieth Volquardsen Chris Ventimiglia Signed
2054 2024-02-23 10:33 Anonymous (not verified) 94.188.205.175 Overgrown Lawn Care & Clean-Up LLC Limited Liability Company 860 Main St. Stanhope, Iowa 50246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-23 Shawn David King shawndavidking@yahoo.com Stanhope Hamilton Iowa Michael Roland King Chrisella Ann King Signed (1) The employer does not elect the employers’ liability coverage. Shawn David King overgrownlawn@yahoo.com Is Owner Stanhope Hamilton Iowa Michael Roland King Chrisella Ann King Signed
876 2022-01-31 11:31 Anonymous (not verified) 75.162.226.236 Leaf Fitters Limited Liability Company 16180 SE Laurel St Des Moines Ia 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-01-31 Rogelio De La Rosa Jr. chucotx@rocketmail.com Des Moines Polk Iowa Noreen Henry Christian Lopez Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Rogelio De La Rosa chucotx@rocketmail.com self Des Moines polk ia noreen henry Christian Lopez Signed
877 2022-01-31 11:43 Anonymous (not verified) 75.162.226.236 Rogelio De La rosa Proprietorship 2104 E 25th St. Des Moines 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. 2022-01-31 Rogelio De La rosa jr chucotx@rocketmail.com Des Moines polk Ia Noreen Henry Christian Lopez Signed (1) The employer does not elect the employers’ liability coverage. Rogelio De La Rosa chucotx@rocketmail.com owner Des moines polk Ia Noreen Henry Christian Lopez Signed
898 2022-02-04 21:46 Anonymous (not verified) 107.77.161.27 Roger De La Rosa Proprietorship 2104 E 25th St Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-04 Roger De La Rosa roger_dlr72@yahoo.com Des Moines Polk IA Noreen Henry Christian Lopez Signed (1) The employer does not elect the employers’ liability coverage. Roger De La Rosa roger_dlr72@yahoo.com Owner Des Moines Polk IA Noreen Henry Christian Lopez Signed
1578 2023-04-17 15:33 Anonymous (not verified) 94.188.205.174 Spark Train Express LLC Limited Liability Company 16877 500th St, Pocahontas, IA 50574 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Austin Sparks sparksaustin.11@gmail.com Pocahontas Pocahontas Iowa Stephanie Webbink Christian Lynch Signed (1) The employer does not elect the employers’ liability coverage. Austin Sparks sparksaustin.11@gmail.com Owner Pocahontas Pocahontas Iowa Stephanie Webbink Christian Lynch Signed
955 2022-03-08 11:21 Anonymous (not verified) 166.181.80.171 JB Roofing & Home Repair Limited Liability Company 453 South Street Kalona, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-08 Jason Boller jbroofhr@gmail.com Kalona Washington IA Jodee Stransky Christian Swartzentruber Signed (1) The employer does not elect the employers’ liability coverage. Christian Swartzentruber christian@fisherins.com Insurance Agent Kalona Washington IA Jodee Stransky Christian Swartzentruber Signed
1362 2022-11-08 08:36 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Proprietorship Box 383 Urbana Iowa 52345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-08 Armin Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Stieferman Christin Martin Signed (1) The employer does not elect the employers’ liability coverage. Armin Martin arminbonnie@aol.com Self Urbana Benton Iowa Melissa Stieferman Christin Martin Signed
1847 2023-09-18 18:20 Anonymous (not verified) 94.188.205.168 William O'Brien Proprietorship 1069 Yukon Ave Sumner Iowa 50674 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 William Charles O'Brien wcobrien63@gmail.com Sumner Bremer Iowa Patrick B Dillon Christina Rader Signed (1) The employer does not elect the employers’ liability coverage. William Charles O'Brien wcobrien63@gmail.com self Sumner Bremer Iowa Patrick B Dillon Christina Rader Signed
180 2020-06-09 13:35 Anonymous (not verified) 99.203.113.208 Z & Sons handyman company LLC Limited Liability Company 2701 E Market St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-09 Miguel Angel Zuniga mazuniga123678@gmail.com Des Moines Polk Iowa Rosario Zuniga Christina Zuniga Signed (1) The employer does not elect the employers’ liability coverage. Miguel Angel Zuniga mazuniga123678@gmail.com Z & Sons handyman company LLC is owned by agent Des Moines Polj Iowa Rosario Zuniga Christina Zuniga Signed
181 2020-06-09 20:44 Anonymous (not verified) 75.162.15.198 Z & Sons handyman company LLC Limited Liability Company 2701 E Market St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-09 Miguel Angel Zuniga mazuniga123678@gmail.com Des Moines Polk Iowa Rosario Zuniga Christina Zuniga Signed (1) The employer does not elect the employers’ liability coverage. Miguel Angel Zuniga mazuniga123678@gmail.com Z & Sons handyman company LLC is owned by agent Des Moines Polk Iowa Rosario Zuniga Christina Zuniga Signed
888 2022-02-03 14:40 Anonymous (not verified) 174.215.230.111 Blakesley Enterprise Proprietorship 609 Center St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 William Blakesley Blakesleyb@msn.com Reinbeck Iowa Iowa Nichelle Blakesley Christine Willis Signed (1) The employer does not elect the employers’ liability coverage. William Blakesley Blakesleyb@msn.com Owner Reinbeck Iowa Iowa Nichelle Blakesley Christine Willis Signed
890 2022-02-03 15:11 Anonymous (not verified) 173.23.180.117 E.A. Electric LLC Limited Liability Company 1065 South Hill Dr, Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 Emin Alibegic emin.alibegic@yahoo.com Waterloo Black Hawk Iowa Nickole Pry Christine Willis Signed (1) The employer does not elect the employers’ liability coverage. Emin Alibegic emin.alibegic@yahoo.com Same Person Waterloo Black Hawk Iowa Nickole Pry Christine Willis Signed
891 2022-02-03 15:25 Anonymous (not verified) 173.23.180.117 Roy Dawson Proprietorship 2602 Green Creek, Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 Roy Dawson roydawson19@gmail.com Cedar Falls Black Hawk County Iowa Nickole Pry Christine Willis Signed (1) The employer does not elect the employers’ liability coverage. Roy Dawson roydawson19@gmail.com Same person Cedar Falls Black Hawk Iowa Nickole Pry Christine Willis Signed
1511 2023-03-09 15:52 Anonymous (not verified) 94.188.205.177 CG Welding Limited Liability Company 5400 147th I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Christopher A Lendt weldingiowa@gmail.com Urandale Dallas IA Chris Lendt Chris Lendt Signed (1) The employer does not elect the employers’ liability coverage. Christopher A Lendt weldingiowa@gmail.com Owner Urandale Dallas IA Christopher Lendt Christopher Lendt Signed
1772 2023-08-01 15:09 Anonymous (not verified) 94.188.205.168 MHI Services Proprietorship 613 Damon St 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. 2023-08-01 Lisa Mitchell lmitchell939@gmail.com Council Bluffs Pottawattamie Iowa Charles Meckna Christopher Young Signed (1) The employer does not elect the employers’ liability coverage. LIsa MItchellj lmitchell939@gmail.com Self Council Bluffs Pottawattamie Iowa Charles Meckna Christopher Young Signed
1502 2023-03-07 12:40 Anonymous (not verified) 94.188.205.177 Joseph Martin Limited Liability Company P O Box 277 Lime Springs, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 Joseph Martin darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Al's Roofing LLC darrele@ciains.biz Member Lime Springs Howard Iowa Darrel Elsbernd Chrus Fye Signed
1470 2023-02-20 08:38 Anonymous (not verified) 94.188.205.167 Level92 Screen Printing LLC Limited Liability Company 2500 W 2nd Ave Ste 10, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Alison Vice orders@level92.com Indianola Warren Iowa Bill Bauer Cindy Bauer Signed (1) The employer does not elect the employers’ liability coverage. Alison Vice orders@level92.com Partner Indianola Warren Iowa Bill Bauer Cindy Bauer Signed
485 2021-04-16 11:58 Anonymous (not verified) 69.57.23.123 CRAIG AUKES Proprietorship 43397 50TH AVENUE, BUFFALO CENTER, IA 50424 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-16 CRAIG AUKES cdaukes@yahoo.com Buffalo Center Winnebago Iowa Steven Heyer Cindy Mawdsley Signed (1) The employer does not elect the employers’ liability coverage. CRAIG AUKES cdaukes@yahoo.com Employer-Proprietor Buffalo Center Winnebago IA Steven Heyer Cindy Mawdsley Signed
605 2021-08-16 16:06 Anonymous (not verified) 67.55.155.46 COMPLETE CONSTRUCTION SERVICES LLC Limited Liability Company 718 FOX RUN I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-16 DAVID BOWER BOWERD@OSKYCSD.ORG OSKALOOSA MAHASKA IOWA JAMES MCNAUL CINDY STEVENSON GRUBB Signed (1) The employer does not elect the employers’ liability coverage. DAVID BOWER BOWERD@OSKYCSD.ORG PRESIDENT OSKALOOSA MAHASKA IOWA JAMES MCNAUL CINDY STEVENSON GRUBB Signed
1801 2023-08-15 14:17 Anonymous (not verified) 94.188.205.168 Mark S Lisiecki Proprietorship 2526 S Arizona RD Apache Junction AZ 85119 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-15 Mark S Lisiecki markslisiecki@yahoo.com Apache Junction PINAL Arizona Simona Valeriano Cindy Ugarte Signed (1) The employer does not elect the employers’ liability coverage. Mark Lisiecki markslisiecki@yahoo.com owner APACHE jUNCTION PINAL AZ Simona Valeriano Cindy Ugarte Signed
1170 2022-06-24 08:52 Anonymous (not verified) 66.255.230.24 Anderson's Flying Service Proprietorship PO Box 127 Robbins, CA 95676 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-24 Stephen Anderson steve@andersonsflying.com YUBA CITY CA United States Greg Foster Cliff Snelling Signed (1) The employer does not elect the employers’ liability coverage. Stephen Anderson steve@andersonsflying.com Self YUBA CITY CA United States Greg Foster Cliff Snelling Signed
1429 2023-01-25 13:43 Anonymous (not verified) 136.35.255.41 J&D Renovations Proprietorship 114 2nd St. Carbon Cliff, IL 61239 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-25 Donald Lane jdrenovations309@gmail.com Carbon Cliff, IL Rock Island County Illinois Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Cody Dubar Signed
813 2021-12-27 10:18 Anonymous (not verified) 172.58.84.252 LLC Partnership 866 40th Ave Bettendorf, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-23 Kimberly Anne Liggitt kliggitt25@gmail.com Rock Island IL United States Suzanne Jeanette Liggitt Christie Marie Liggitt Signed (1) The employer does not elect the employers’ liability coverage. Cody Dunbar codydunbar@leaffilter.com Manager 866 40th Ave Bettendorf ia 52722 Scott County IA Jordan nisiewicz Cody Dunbar Signed
894 2022-02-04 11:18 Anonymous (not verified) 152.117.105.90 Dusty schraceo Proprietorship 712 E 15th St Davenport, IA, 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-04 Dusty Schraceo dustyschraceo1999@gmail.com Davenport Scott Iowa Tiffani Branham Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Dusty Schraceo dustyschraceo1999@gmail.com Self Davenport Scott Iowa Tiffani Branham Cody Dunbar Signed
1038 2022-04-11 09:43 Anonymous (not verified) 173.27.156.183 JABS Construction/Finish Limited Liability Company 543 10th Ave. S. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-11 Roberto John Henrickson henricksonroberto10@gmail.com Clinton IA United States Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay County Missouri Roberto J Henrickson Cody Dunbar Signed
1854 2023-09-27 11:22 Anonymous (not verified) 94.188.205.174 Wen Boatwright Proprietorship 4200 Indianola Ave Des Moines, IA 50320 United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-27 Wen Boatwright wenboatwrght@gmail.com Des Moines Des Moines Iowa Jordan Nisiewicz Cody Dunbar Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson Missouri Jordan Loyd Cody Dunbar Signed
2135 2024-04-04 11:02 Anonymous (not verified) 94.188.207.227 Jonathan Warner Proprietorship 420 16th Avenue, East Moline, IL 61244, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-04 Jonathan Warner bsguttersllc@gmail.com East Moline, IL Moline Illinois Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson MO Jordan Loyd Cody Dunbar Signed
2151 2024-04-15 14:42 Anonymous (not verified) 94.188.207.227 Jose Acuna Proprietorship 1015 East Main Street, Belmond, IA 50421, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-15 Jose Acuna Joseacuna@gmail.com Belmond, IA Wright Iowa Jordan Loyd Jordan Nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson Missouri Jordan Loyd Cody Dunbar Signed
270 2020-09-25 10:14 Anonymous (not verified) 174.243.97.206 J Watts Electric Limited Liability Company 615 E 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. 2020-09-25 Jason Watts jason.watts@jwattselectric.com Webster City Hamilton Iowa Eli Ochoa Cody Ewing Signed (1) The employer does not elect the employers’ liability coverage. Jason Watts jason.watts@jwattselectric.com Self Webster City Hamilton Iowa Eli Ochoa Cody Ewing Signed
1051 2022-04-14 17:56 Anonymous (not verified) 199.59.236.46 Triple M Welding Proprietorship 407 4th St Sw I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Matthew Gibson matthew.gibson02003@gmail.com Independence Iowa Iowa Brandon Keener Cody Laughlin Signed (1) The employer does not elect the employers’ liability coverage. Matthew Gibson matthew.gibson02003@gmail.com Owner Independence Iowa Iowa Brandon Keener Cody Laughlin Signed
119 2020-04-14 14:38 Anonymous (not verified) 66.188.136.150 Matthew Popejoy Proprietorship 7897 21st Ave., Blaristown, IA 52209 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-14 Matthew Popejoy popejoymatthew@gmail.com Blairstown Benton IA Russell Masartis Cody McClain Signed (1) The employer does not elect the employers’ liability coverage. Dan Oberfoell doberfoell@tricorinsurance.com Agent Blairstown Benton IA Russell Masartis Cody McClain Signed
555 2021-07-06 12:06 Anonymous (not verified) 66.188.136.150 Damond Horner Proprietorship 44 East Grove Monroe, MI 48162 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-02 Damond Horner kschumacher@tricorinsurance.com Monroe Monroe MI Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Damond Horner kschumacher@tricorinsurance.com Same Monroe Monroe MI Mitch Kemp Cody McClain Signed
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
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
441 2021-03-18 16:20 Anonymous (not verified) 173.25.156.33 CYALCO AVIATION LLC Limited Liability Company 3710 W. MILWAUKEE ST, SPENCER, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-03-18 WILLIAM A. VAN LENT bvl@veridian.net WEST DES MOINES POLK IOWA ERIN MONFORT NELSON COLE M. VAN LENT Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. WILLIAM A. VAN LENT bvl@veridian.net SAME WEST DES MOINES POLK IOWA ERIN MONFORT NELSON COLE M. VAN LENT Signed
548 2021-06-24 22:08 Anonymous (not verified) 173.31.28.69 Brown's Window Cleaning +PLUS Proprietorship 700 11th 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. 2021-06-24 Lawrence Brown brownswindowcleaningplus@gmail.com Altoona Iowa United States Jason Alderman Colette Evans Signed (1) The employer does not elect the employers’ liability coverage. Lawrence Brown brownswindowcleaningplus@gmail.com Self Altoona Iowa United States Jason Alderman Colette Evans Signed
761 2021-11-22 07:22 Anonymous (not verified) 73.211.163.27 James crockett Limited Liability Company 417 easr st south Kewanee il 61443 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-22 James crockett tattoojec@gmail.com Kewanee il Henery Il Tom mcintire Colton english Signed (1) The employer does not elect the employers’ liability coverage. Hog city construction tattoojec@gmail.com Self Kewanee Henery Il Tom mcintire Colon english Signed
1831 2023-09-08 11:50 Anonymous (not verified) 94.188.207.223 GFORCE Limited Liability Company 529 Anderson Street Jewell IA 50130 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-06 Colten Abram Griffin G6@q.com Ames Story Iowa Scott Andrew Griffin Hunter Austin Griffin Signed (1) The employer does not elect the employers’ liability coverage. Hunter Austin Griffin G6@q.com Partner Urbandale Polk Iowa Scott Andrew Griffin Colten Abram Griffin Signed
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
965 2022-03-10 12:44 Anonymous (not verified) 107.115.239.27 KG Land Works LLC Limited Liability Company P.O. Box 931 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-10 Dalton Gregory Gardner kglandworks@gmail.com Barnsdall Osage Oklahoma Dalton Gardner Colton Kelley Signed (1) The employer does not elect the employers’ liability coverage. Dalton Gardner kglandworks@gmail.com Owner Barnsdall Osage Oklahoma Dalton Gardner Colton Kelley Signed
864 2022-01-27 12:50 Anonymous (not verified) 67.55.155.207 Chamra Farms Limited Liability Company 3031 215 th 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. 2022-01-01 Andy Chamra apchamra@gmail.com Rose Hill Iowa United States Steve Weller Connie VanKlootwyk Signed (1) The employer does not elect the employers’ liability coverage. Steven Weller steve.weller@insurancestationinc.com Agent OSKALOOSA Iowa United States Andy Chamra Connie Van Klootwyk Signed
865 2022-01-27 12:53 Anonymous (not verified) 67.55.155.207 Chamra Farms Limited Liability Company 3031 215 th 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. 2022-01-01 Roy Chamra apchamra@gmail.com Rose Hill Iowa United States Steven Weller Connie VanKlootwyk Signed (1) The employer does not elect the employers’ liability coverage. Steven Weller steve.weller@insurancestationinc.com Agent OSKALOOSA Iowa United States Roy Chamra Connie Van Klootwyk Signed
1324 2022-09-30 10:19 Anonymous (not verified) 172.86.18.249 Red Beard Buildings Limited Liability Company 511 16th St. Belle Plaine, IA 52208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-30 Austin Carnes austin_carnes@hotmail.com Belle Plaine Benton IA Craig Roster Connor Doran Signed (1) The employer does not elect the employers’ liability coverage. Austin Carnes austin_carnes@hotmail.com President Belle Plaine Benton IA Craig Roster Connor Doran Signed
862 2022-01-27 12:02 Anonymous (not verified) 174.198.81.166 Big Bear Construction,LLC Limited Liability Company 4508 Hiawatha Ave 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. 2022-01-27 Michael Allen Becker mike4bbc@gmail.com Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed (1) The employer does not elect the employers’ liability coverage. Kevin Paul Becker jr kbeckerbbc@gmail.com Brother/partner Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed
863 2022-01-27 12:13 Anonymous (not verified) 174.198.81.166 Big Bear Construction llc Limited Liability Company 4508 Hiawatha Ave ne Cedar Rapids iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-27 Kevin Paul Becker jr kbeckerbbc@gmail.com Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed (1) The employer does not elect the employers’ liability coverage. Michael Allen Becker mike4bbc@gmail.com Brother/Partner Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed
1122 2022-05-21 12:19 Anonymous (not verified) 173.24.108.210 Daly Building Service,LLc Limited Liability Company 409 Dammann dr. Eldridge IA, 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-21 Noah Daly Noahdalyubs@gmail.com Eldridge Scott County Iowa Holly Roberts Corinna Daly Signed (1) The employer does not elect the employers’ liability coverage. Derick Perry biglakellc@outlook.com Liability policy agent Eldridge Scott county Iowa Holly roberts Corinna Daly Signed
1331 2022-10-11 13:17 Anonymous (not verified) 174.216.2.52 Parceros Construction LLC Limited Liability Company 2315 Landon Rd. Apt. 206 North Liberty, IA 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-11 Laura Garavito ldanielagaravitog@gmail.com North Liberty Johnson IA Derek Davis Cory Beesler Signed (1) The employer does not elect the employers’ liability coverage. Laura Garavito ldanielagaravitog@gmail.com Owner North Liberty Johnson IA Derek Davis Cory Beesler Signed
312 2020-11-11 18:12 Anonymous (not verified) 173.16.216.53 Skb transportation llc Limited Liability Company 401 6th street west amana iowa 52203 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-11 Scott Wayne bryant skbtransportation@icloud.com West amana Iowa Iowa Nichole prokop Cory prokop Signed (1) The employer does not elect the employers’ liability coverage. Scott Wayne bryant skbtransportation@icloud.com Owner West amana Iowa Iowa Nichole prokop Cory prokop Signed
1095 2022-05-12 13:20 Anonymous (not verified) 173.31.29.53 Leaf cutter protection Limited Liability Company 4146 East 23rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-05-12 Gideon Lagat gsaina78@gmail.com Des Moines IA United States Priscilla saina Cosmas nyaika Signed (1) The employer does not elect the employers’ liability coverage. Mark rond mbond@leaffilter.com Regional installation Manager Grimes Polk Iowa Priscilla saina Cosmas nyaika Signed
1402 2022-12-28 16:35 Anonymous (not verified) 208.69.145.91 DeRonde Flooring Inc. Proprietorship 3612 NW 178th Ct, 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. 2022-12-28 Brian DeRonde derondeflooring@gmail.com Clive Dallas IA Brian DeRonde Courtney DeRonde Signed (1) The employer does not elect the employers’ liability coverage. Brian DeRonde derondeflooring@gmail.com Self Clive Dallas IA Brian DeRonde Courtney DeRonde Signed
1971 2023-12-29 19:27 Anonymous (not verified) 94.188.207.223 Megan Thibodeau Proprietorship 4301 Adams Ave, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-29 Megan E Thibodeau megancallan@hotmail.com Des Moines Iowa United States Travis Releford Courtney Releford Signed (1) The employer does not elect the employers’ liability coverage. Megan E Thibodeau megancallan@hotmail.com Self Des Moines Iowa United States Travis Releford Courtney Releford Signed
1267 2022-08-17 14:11 Anonymous (not verified) 174.192.75.162 Elijah wyant Proprietorship 708 1/2 w 3rd st davenport ia 52802 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-17 Elijah wyant Aidenwyant@gmail.com Davenport Scott Iowa Jake laxton Courtney sanders Signed (1) The employer does not elect the employers’ liability coverage. Elijah wyant Aidenwyant@gmail.com Self Davenport Scott Iowa Jake laxton Courtney sanders Signed
405 2021-02-17 11:04 Anonymous (not verified) 104.201.67.178 CYE Painting Limited Liability Company 5202 SE 31st Ct Des Moines,IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-17 CYE Painting marilopez9657@yahoo.com Des Moines Polk Iowa Maricela Lopez Cruz Cabrera Signed (1) The employer does not elect the employers’ liability coverage. Maricela Lopez marilopez9657@yahoo.com N/a Des Moines Polk IA Maricela Lopez Cruz Cabrera Signed
255 2020-09-11 13:42 Anonymous (not verified) 173.190.65.6 A Fisk Trucking, LLC Limited Liability Company PO Box 332, Strawberry Point, IA 52076 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-14 Andrew Fisk afisktrucking@gmail.com Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole Signed (1) The employer does not elect the employers’ liability coverage. A Fisk Trucking, LLC afisktrucking@gmail.com Member/Manager Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole 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
954 2022-03-08 11:07 Anonymous (not verified) 174.192.138.191 Duwa Waterproofing Limited Liability Company 729 Deer View 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. 2022-03-08 Stacy Duwa duwawaterproofing@gmail.com Tiffin Johnson Iowa Chad Cooper Curtis Sexton Signed (1) The employer does not elect the employers’ liability coverage. Stacy Duwa duwawaterproofing@gmail.com President Tiffin Johnson Iowa Chad Cooper Curtis Sexton Signed
824 2022-01-06 20:57 Anonymous (not verified) 209.252.175.92 Rottweiler Remodel & Repair LLC Limited Liability Company 1503 10th Ave Sw Cedar Rapids Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-06 Zechariah Robert DeLaVergne rottweilerremodel@gmail.com Cedar Rapids Linn County Iowa Kathy Maxine Morgan Daisha Rae Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Zechariah DeLaVergne rottweilerremodel@gmail.com Owner Cedar Rapids Linn County Iowa Kathy Maxine Morgan daisha rae gonzalez Signed
2181 2024-04-25 15:41 Anonymous (not verified) 94.188.205.168 Ev's Ice Cream LLC Limited Liability Company 2205 1/2 S Center St, Marshalltown, IA 50158-5960 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-25 Kathryn Perry-Jenkins hawkeyesfan.22.kp@gmail.com Marshalltown Marshall IA Rebecca Houg Dakota Himes Signed (1) The employer does not elect the employers’ liability coverage. Kathryn Perry-Jenkins hawkeyesfan.22.kp@gmail.com Self Marshalltown Marshall IA Rebecca Houg Dakota Himes Signed
964 2022-03-10 12:41 Anonymous (not verified) 107.115.239.27 KG Land Works LLC Limited Liability Company P.O. Box 931 Barnsdall Ok 74002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-10 Colton Kelley kglandworks@gmail.com Barnsdall Osage Oklahoma Colton Kelley Dalton Gardner Signed (1) The employer does not elect the employers’ liability coverage. Colton Kelley kglandworks@gmail.com Owner Barnsdall Osage Oklahoma Colton Kelley Dalton Gardner Signed
1032 2022-04-05 09:21 Anonymous (not verified) 75.89.4.2 KG land works Limited Liability Company 812 cr 2401 barnsdall Oklahoma 74002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Wyatt ray slone wyattslone177@gmail.com Barnsdalll Osage OK Dalton Gardner Colton Kelley Signed (1) The employer does not elect the employers’ liability coverage. Colton Kelley kglandworks@gmail.com Day helper Barnsdalll Osage OK Colton Kelley Dalton Gardner Signed
1428 2023-01-23 19:31 Anonymous (not verified) 206.72.6.241 Brian Grote Limited Liability Company 919 Highway 37 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-23 Brian Grote grote919@gmail.com Earling Iowa United States Jaurel Grote Dan Grote Signed (1) The employer does not elect the employers’ liability coverage. Leinen Construction grote919@gmail.com sub Harlan Iowa Iowa United States Jaurel Grote Dan Grote Signed
483 2021-04-16 10:47 Anonymous (not verified) 204.155.61.217 Joseph Jones DBA Jones Sealcoating and Asphalt Repair Limited Liability Company 1033 Hummingbird 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. 2021-04-16 Joseph Jones iscrapcu@yahoo.com Waterloo Iowa Iowa Kyle Hildman Dan Sinnott Signed (1) The employer does not elect the employers’ liability coverage. Jospeh Jones iscrapcu@yahoo.com OWNER Waterloo Black Hawk IA Kyle Hildman Dan Sinnott Signed
639 2021-09-13 16:10 Anonymous (not verified) 50.81.97.207 Copic Home Maintenance LLC dba Des Moines Drywall Repair Limited Liability Company 1548 24th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-13 Clint R Copic crcopic@gmail.com Des Moines Polk Iowa Veronica G. Torres Dan Waidelich Signed (1) The employer does not elect the employers’ liability coverage. Clint R Copic dmdrywallrepair@gmail.com self Des Moines Polk Iowa Veronica G Torres Dan Waidelich Signed
376 2021-01-26 11:14 Anonymous (not verified) 173.28.210.45 Cross Medical Lab, L.L.P Limited Liability Partnership 500 E Market St Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-26 Aaron Klein lhavel_23@gmail.com Iowa City Johnson Iowa Ashley Lee Dan Wegman Signed (1) The employer does not elect the employers’ liability coverage. Lori Havel lhavel_23@gmail.com Office Manager Iowa CIty Johnson IA Ashley Lee Dan Wegman Signed
530 2021-05-25 08:30 Anonymous (not verified) 159.242.43.24 FoxTrot Foods, LLC Limited Liability Company 13-15 S Federal Ave, Mason City IA 50401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-25 Melissa Fabian melissafabian@yahoo.com Mason City Cerro Gordo Iowa Jenny McIntyre Dan Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Melissa Fabian melissafabian@yahoo.com Owner-Member Mason City Cerro Gordo Iowa Jenny McIntyre Dan Wunschel Signed
697 2021-10-28 15:30 Anonymous (not verified) 208.126.114.236 bartman express Limited Liability Company 1976 240th st bennett iowa 52721 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 bartin joesph steines bartmanexpress@gmail.com bennett cedar iowa Robert theordore jarrett dana marie shipler Signed (1) The employer does not elect the employers’ liability coverage. bartin joesph steines bartmanexpress@gmail.com self bennett cedar iowa robert theordore jarrett dana marie shipler Signed
773 2021-11-24 14:48 Anonymous (not verified) 24.149.18.237 The Ragged Edge Art Bar and Gallery Limited Liability Company 504 Bluff Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-24 Kendra Wohlert kwohlert43@gmail.com CEDAR FALLS IA United States Theresa Johnson Danette Priebe Signed (1) The employer does not elect the employers’ liability coverage. Kendra Wohlert kwohlert43@gmail.com self CEDAR FALLS IA United States Theresa Johnson Danette Priebe Signed
287 2020-10-21 18:35 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Gary George Bilyeu garygb1990@gmail.com Sparta Christian Missouri Daniel Bilyeu Chad Anthony Charles Signed (1) The employer does not elect the employers’ liability coverage. Gary George Bilyeu garygb1990@gmail.com Owner Sparta Christian Missouri Chad Anthony Charles Daniel Bilyeu Signed
288 2020-10-21 18:36 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Chad Anthony Charles y4ardgn0m3r@gmail.com Nixa Christian Missouri Gary George Bilyeu Daniel Bilyeu Signed (1) The employer does not elect the employers’ liability coverage. Chad Anthony Charles y4ardgn0m3r@gmail.com Owner Nixa Christian Missouri Gary George Bilyeu Daniel Bilyeu Signed
1451 2023-02-13 13:27 Anonymous (not verified) 94.188.205.168 Better Built Floors, LLC Limited Liability Company 950 Spruce street Waukee, IA, 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-13 Bodhi Cox betterbuiltfloors@gmail.com waukee dallas iowa Bodhi Cox Daniel Cox Signed (1) The employer does not elect the employers’ liability coverage. Bodhi Cox betterbuiltfloors@gmail.com i am thge owner/operator waukee dallas iowa Bodhi Cox Daniel Cox Signed
325 2020-11-23 11:14 Anonymous (not verified) 174.198.82.169 Dan davidson Limited Liability Company 21Lincoln 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-22 Daniel Lee davidson unitedremodelingdd@gmail.com Palo Linn IA Daniel Lee davidson Daniel Lee davidson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Daniel Lee davidson unitedremodelingdd@gmail.com Owner Palo Linn IA Daniel Lee davidson Daniel Lee davidson Signed
1378 2022-11-21 15:12 Anonymous (not verified) 136.34.59.85 Jake Jones Proprietorship 203 9th Ave. Colona, Il 61241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-21 Jake Jones jmjones807@gmail.com Colona Henry Illinois Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional Recruiter Kansas City Clay Missouri Jordan Loyd Daniel Neal Signed
328 2020-11-26 12:28 Anonymous (not verified) 174.198.82.38 Duke millwright doing business as duke & sons Limited Liability Company 3264 e Payton ave Des Moines iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-26 Jeremiah duke jpduke24.7.365@gmail.com Des Moines Polk county Iowa Daniel Patrick Hemann Nikki Marie Harvey Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Diana duke dukemillwright@gmail.com Self Des Moines Polk Iowa Nikki Marie Harvey Daniel Patrick Hemann Signed
775 2021-12-02 11:40 Anonymous (not verified) 65.144.174.26 Pedro Campos Proprietorship 16901 SW 13th St, Des Moines, IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-02 Pedro Campos camposp113@msn.com Des Moines Polk IA Antonio Campos Daniel Perez Signed (1) The employer does not elect the employers’ liability coverage. Pedro Campos camposp113@msn.com Self Des Moines Polk Iowa Antonio Campos Daniel Perez Signed
1840 2023-09-14 13:48 Anonymous (not verified) 94.188.207.228 L.R. Construction, LLC Limited Liability Company 1564 110th Street, Hazleton, IA 50641 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-23 Levi R Raber amish@amish.com Hazleton Buchanan Iowa Mary Ann Raber Daniel Raber Signed (1) The employer does not elect the employers’ liability coverage. Levi R Raber amish@amish.com self Hazleton BUCHANAN Iowa Mary Ann Raber Daniel Raber Signed
1288 2022-08-30 16:23 Anonymous (not verified) 50.83.35.94 Black Rock Flooring LLC Limited Liability Company 189 9th st. Marion,Ia 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-30 Keith Douglas Luye Sr. Blackrockflooriing@gmail.com Marion Linn Iowa Cari Beth Lamb Daniel Ray Lamb Signed (1) The employer does not elect the employers’ liability coverage. Keith Douglas Luye Sr. Blackrockflooring@gmail.com self / my own authorized agent Marion Linn Iowa Cari Beth Lamb Daniel Ray Lamb Signed
242 2020-08-24 09:27 Anonymous (not verified) 159.242.43.24 Bontreger Seamless Gutters Proprietorship 501 S Center St. Zearing Ia 50278 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Bontreger borntrgerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Bontreger borntrgerharvey@gmail.com Owner Zearing Story Ia Alex G Meier Daniel Wunschel Signed
243 2020-08-24 11:31 Anonymous (not verified) 159.242.43.24 Borntreger Seamless Gutters Proprietorship 501 S Center St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Borntrager Borntregerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Borntreger borntregerharvey@gmail.com Owner Zearing Story Ia Alex Meier Daniel Wunschel Signed
436 2021-03-16 13:37 Anonymous (not verified) 141.193.221.33 Custom Applicationz Partnership 13220 Hwy S70 Plano, IA 52581 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-16 Zebulun Joiner joinerconst@gmail.com Plano Appanoose IA Danielle Joiner Zebulun Joiner Signed (1) The employer does not elect the employers’ liability coverage. Danielle Joiner joinerconst@gmail.com Self/Wife of Partner Plano Appanoose IA Zebulun Joiner Danielle Joiner Signed
1906 2023-11-14 13:47 Anonymous (not verified) 94.188.207.223 HRBC Plus Limited Liability Company 249 SOLOMIA CT, Peosta, IA 52068 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-11 Lori S Stewart lori@hrbcplus.com PEOSTA Dubuque United States Mark R Stewart Danielle M Leibfried Signed (1) The employer does not elect the employers’ liability coverage. Lori Stewart lori@hrbcplus.com Self Peosta Dubuque United States Mark R Stewart Danielle M Peterson Signed
1874 2023-10-22 11:54 Anonymous (not verified) 94.188.205.166 Midwest UAV LLC Limited Liability Company 1400 15th St SE Bondurant Iowa 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-22 Kaleb Thomas Trammell kttrammell05@gmail.com Bondurant Polk IA Alan Willis Danielle Trammell Signed (1) The employer does not elect the employers’ liability coverage. Kaleb Thomas Trammell kttrammell05@gmail.com Owner Bondurant Polk IA Alan Willis Danielle Trammell Signed
362 2021-01-14 12:15 Anonymous (not verified) 173.26.157.255 Shear Bliss Pet Salon Limited Liability Company 824 Ansborough Ave. Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-14 Sarah K Bebee shearblisspet@aol.com Hudson Black Hawk Iowa Janice Rae Bebee Danny J Bebee Signed (1) The employer does not elect the employers’ liability coverage. Sarah Bebee shearblisspet@aol.com self Hudson Black Hawk Iowa Janice Rae Bebee Danny J Bebee Signed
363 2021-01-14 12:17 Anonymous (not verified) 173.26.157.255 Shear Bliss Pet Salon Limited Liability Company 824 Ansborough Ave. Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-14 Melissa Kay Herold shearblisspet@aol.com Cedar Falls Black Hawk Iowa Janice Rae Bebee Danny J Bebee Signed (1) The employer does not elect the employers’ liability coverage. Meliss Kay Herold shearblisspet@aol.com self Cedar Falls Black Hawk Iowa Janice Rae Bebee Danny J Bebee Signed
1909 2023-11-15 12:27 Anonymous (not verified) 94.188.207.228 CHAR-LES BUILDINGS LLC Limited Liability Company 14633 7TH AVE NW, ANDOVER MN 55304 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-15 JOHNNY CHAVEZ CHAVEZ charlychavez151@gmail.com ANDOVER ANOKA MINNESOTA ALEIDA LEE DANY JIMBO Signed (1) The employer does not elect the employers’ liability coverage. JOHNNY CHAVEZ CHAVEZ charlychavez151@gmail.com OWNER ANDOVER ANOKA MINNESOTA ALEIDA LEE DANY JIMBO Signed
1323 2022-09-28 22:45 Anonymous (not verified) 74.51.212.66 OUTDOOR MODERN CONCEPTS LLC Limited Liability Company 2520 RIVER MEADOWS DR., DES MOINES, IA, 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-28 CHRISTIAN RUBIO RUBIOCH39@GMAIL.COM DES MOINES POLK IOWA AMANDA DUPRE DARCI CLARK Signed (1) The employer does not elect the employers’ liability coverage. JENNIFER B. CHAVEZ-RIVERA JENNIFER.CHAVEZ-RIVERA@BROWNWINICK.COM ATTORNEY DES MOINES POLK IOWA AMANDA DUPRE DARCI CLARK Signed
1859 2023-10-04 07:54 Anonymous (not verified) 94.188.205.167 Pacheco Constructrion Limited Liability Company 1614 Center Street, Des Moines IA 50314 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-04 Ulises Pacheco info@pachecoconstruction.com Des Moines Polk Iowa Melissa Gray Darci Rene Pacheco Signed (1) The employer does not elect the employers’ liability coverage. Ulises Pacheco info@pachecoconstruction.com Self Des Moines Polk Iowa Melissa Gray Darci Rene Pacheco Signed
2024 2024-02-06 20:31 Anonymous (not verified) 94.188.207.223 BTS Custom Floors Proprietorship 22 wenwood 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. 2024-02-06 Brandon Clay Brandon.btscustomfloors@gmail.com Council Bluffs Iowa United States Darin Thompson Amber Swanson Signed (1) The employer does not elect the employers’ liability coverage. Brandon Clay Brandon.btscustomfloors@gmail.com I am them Council Bluffs Iowa United States Amber Swanson Darin Thompson Signed
826 2022-01-10 12:26 Anonymous (not verified) 104.128.43.204 Wolfman Trucking, LLC Limited Liability Company 406 S Lawrence St, Bazine, KS 67516 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-10 JR Steckline wolfmantrucking317@gmail.com Bazine Ness Kansas James Babcock Darin Wittman Signed (1) The employer does not elect the employers’ liability coverage. JR Steckline wolfmantrucking317@gmail.com Owner Bazine Ness Kansas James Babcock Darin Wittman Signed
1954 2023-12-13 13:51 Anonymous (not verified) 94.188.207.227 Beeson Trucking LLC Limited Liability Company 219 Tilden St Kingsley IA 51028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-13 Jeremy Beeson jeremy4k78@yahoo.com Kingsley Plymouth IA Katherine Weaver Darla Robley Signed (1) The employer does not elect the employers’ liability coverage. Jeremy Beeson jeremy4k78@yahoo.com Self Kingsley Plymouth IA Katherine Weaver Darla Robley Signed
2072 2024-03-01 11:27 Anonymous (not verified) 94.188.207.226 SoldFast Real Estate L.L.C. Limited Liability Company 5525 Meredith Drive Des Moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-02 Darlyn Fructuoso thejjscleaningllc@gmail.com Des Moines Polk IA Beatriz Musselman Darlyn Fructuoso Signed (1) The employer does not elect the employers’ liability coverage. Cody Wilkinson cody@soldfast.com Contractor Des Moine Polk IA Beatriz Musselman Darlyn Fructuoso Signed
49 2020-01-31 12:53 Anonymous (not verified) 74.84.121.206 Cody Kleppe Proprietorship 1891 337th St Decorah IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-31 Cody Kleppe darrele@ciains.biz Decorah Winneshiek Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Decorah Winneshiek Iowa Chris Fye Darrel Elsbernd Signed
1338 2022-10-17 15:53 Anonymous (not verified) 74.84.121.206 Mark Mitchell Proprietorship P O Box 38 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-15 Mark Mitchell darrele@ciains.biz New Albion Allamakee Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Mark Mitchell darrele@ciains.biz Self New Albion Allamakee Iowa Chris Fye Darrel Elsbernd Signed
1394 2022-12-14 14:31 Anonymous (not verified) 74.84.121.206 Benjamin Salo Proprietorship 320 Plat St Lansing, IA 52151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Benjamin Salo benwa011@gmail.com Lansing, Iowa Allamakee Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Benjamin Salo benwa011@gmail.com self Lansing Allamakee Iowa Chris Fye Darrel Elsbernd Signed
1489 2023-02-28 16:06 Anonymous (not verified) 94.188.207.228 Nate's Tractor LLC Limited Liability Company 11939 birch Ave Riceville, IA 50466 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-28 Nathan Fox nate@natestractor.com Riceville Howard Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Nathan Fox nate@natestractor.com Member Riceville Howard Iowa Chris Fye Darrel Elsbernd Signed
1903 2023-11-13 09:08 Anonymous (not verified) 94.188.207.228 Christopher Stone Proprietorship 2427 S Taft Ave Apt #8 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-10 Christopher Stone darrele@ciains.biz Iowa Cerro Gordo IA Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Christopher Stone darrele@ciains.biz self Mason City Cerro Gordo Iowa Chris Fye Darrel Elsbernd Signed
1904 2023-11-13 09:27 Anonymous (not verified) 94.188.207.224 Paul White Proprietorship 4991 Old C Boscobel, WI 53805 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-10 Paul White darrele@ciains.biz Boscobel Grant Wisconsin Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Paul White darrele@ciains.biz self Boscobel Grant Wisconsin Chris Fye Darrel Elsbernd Signed
1921 2023-11-22 12:14 Anonymous (not verified) 94.188.205.177 Julie Drtina Proprietorship Cresco 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. 2023-11-22 Julie Drtina juliedrtina@hotmail.com Cresco Howard Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Julie Drtina juliedrtina@hotmail.com self Cresco Howard Iowa Chris Fye Darrel Elsbernd Signed
1966 2023-12-27 13:17 Anonymous (not verified) 94.188.205.177 Jake Borntreger Proprietorship 50 Stone St Clermont, 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. 2022-02-25 Jake Borntreger darrele@ciains.biz Clermont Fayette Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Jake Borntreger darrele@ciains.biz self Clermont Fayette Iowa Chris Fye Darrel Elsbernd Signed
1967 2023-12-27 13:28 Anonymous (not verified) 94.188.207.225 Marvin Gingrich Proprietorship 114641 Chariot Rd Elgin 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. 2022-02-25 Marvin Gingerich darrele@ciains.biz Elgin Fayette Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Marvin Gingerich darrele@ciaisn.biz Self Elgin Fayette Iowa Chris Fye Darrel Elsbernd Signed
1979 2024-01-08 14:59 Anonymous (not verified) 94.188.205.167 Nathan Troendle Proprietorship Lansing 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. 2024-01-05 Nathan Troendle darrele@ciains.biz Lansing Allamakee Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Nathan Troendle darrele@ciains.biz self Lansing Allamakee Iowa Chris Fye Darrel Elsbernd Signed
832 2022-01-12 17:23 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-13 Braden L Gray grayb2014@gmail.com Cedar Falls Black Hawk County Iowa Kari Houle Darren Dean Fanning Signed (1) The employer does not elect the employers’ liability coverage. Cory Allen Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Darren Dean Fanning Signed
1871 2023-10-18 10:27 Anonymous (not verified) 94.188.205.169 Derik Gonyier Proprietorship 1421 Chicago Ave, Savanna, IL 61074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-14 Derik Ray Gonyier deriknalexis121413@gmail.com Savanna Carroll IL Kyle Lee Sturtz Daryl Gonyier Signed (1) The employer does not elect the employers’ liability coverage. Derik Ray Gonyier deriknalexis121413@gmail.com Self Savanna Carroll IL Kylee Lee Daryl Eugene Gonyier Signed
1872 2023-10-18 10:59 Anonymous (not verified) 94.188.205.177 Derik Gonyier Proprietorship 1421 Chicago Ave, Savanna, IL 61074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-14 Derik Ray Gonyier deriknalexis121413@gmail.com Savanna Carroll IL Kyle Lee Sturtz Daryl Eugene Gonyier Signed (1) The employer does not elect the employers’ liability coverage. Derik Ray Gonyier deriknalexis121413@gmail.com Self Savanna Carroll IL Kyle Lee Sturtz Daryl Eugene Gonyier Signed
1907 2023-11-15 09:45 Anonymous (not verified) 94.188.205.168 Dan Taylor Proprietorship 1422 State 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. 2023-11-15 Daniel Taylor mailrunner1958@gmail.com Mason City Cerro Gordo IA Bob Smith Dave Clark Signed (1) The employer does not elect the employers’ liability coverage. Daniel Taylor mailrunner1958@gmail.com employee Mason City Cerro Gordo IA Bob Smith Dave Clark Signed
1804 2023-08-16 18:22 Anonymous (not verified) 94.188.207.226 Zach Moyle Masonry Limited Liability Company 7222 Great River Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-16 Zach Moyle zmoylemasonry@gmail.com Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle Signed (1) The employer does not elect the employers’ liability coverage. Zach Moyle zmoylemasonry@gmail.com Self Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle 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
1731 2023-07-10 11:12 Anonymous (not verified) 94.188.207.228 Romer & Associates LLC Limited Liability Company 433 Thomas Avenue, Maquoketa, IA 52060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-10 Clay K Romer connellsupply@aol.com Maquoketa Jackson IA Susan Croatt Dave Stockham Signed (1) The employer does not elect the employers’ liability coverage. Clay K Romer connellsupply@aol.com Owner/same Maquoketa Jackson IA Susan Croatt Dave Stockham Signed
1956 2023-12-14 13:45 Anonymous (not verified) 94.188.207.226 Fey Concrete Inc Proprietorship 307 East Judson St, Maquoketa, IA 52060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-14 Charles W Fey chuckfey55@gmail.com Maquoketa Jackson Iowa Susan Croatt Dave Stockham Signed (1) The employer does not elect the employers’ liability coverage. Charles W Fey chuckfey55@gmail.com Owner/same Maquoketa Jackson Iowa Susan Croatt Dave Stockham Signed
390 2021-02-10 14:24 Anonymous (not verified) 173.24.190.134 King Excavation, LLC Limited Liability Company 5343 410th St, Cylinder IA 50528 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Aletha King aletha1949@ncn.net Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed (1) The employer does not elect the employers’ liability coverage. Aletha King aletha1949@ncn.net Member of LLC Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed
391 2021-02-10 14:27 Anonymous (not verified) 173.24.190.134 King Excavation, LLC Limited Liability Company 5343 410th St, Cylinder IA 50528 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Beth King aletha1949@ncn.net Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed (1) The employer does not elect the employers’ liability coverage. Beth King aletha1949@ncn.net Member of LLC Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed
443 2021-03-22 13:22 Anonymous (not verified) 167.127.218.244 Romero Carpentry Proprietorship 2060 King Ave, Apt 19, Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-22 Jose Wilber Romero Batres Josew.batres@icloud.com Des moines Polk United States Gabriela Cecibel Chicas David Antonio Barrera Serrano Signed (1) The employer does not elect the employers’ liability coverage. Jose Wilber Romero Batres Josew.batres@icloud.com Self Des Moines Polk Iowa Gabriela Cecibel Chicas David Antonio Barrera Serrano 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
565 2021-07-08 13:42 Anonymous (not verified) 173.25.132.255 Communications Construction Services LLC Limited Liability Company 1315 East 38th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-08 John McCann Jr communicationconstructionllc@gmail.com Des Moines IA United States Laura McCann David Garza Signed (1) The employer does not elect the employers’ liability coverage. Laura McCann communicationconstructionllc@gmail.com spouse Des Moines IA United States John J McCann Jr David Christopher Garza III Signed
1415 2023-01-09 10:50 Anonymous (not verified) 73.103.30.27 MWK Solutions, LLC Limited Liability Company 1001 South Park St., Fairfield, IA 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-09 Michael Wayne Koch mwkpar@gmail.com Fairfield Jefferson Iowa Ann Koch David Fleming Signed (1) The employer does not elect the employers’ liability coverage. Michael Wayne Koch mwkpar@gmail.com Self Fairfield Jefferson Iowa Ann Koch David Fleming 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
2046 2024-02-15 11:29 Anonymous (not verified) 94.188.205.175 Ervin Cabrera Mendez Proprietorship 4822 Meadowlark Lane, Sioux City, Iowa 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. 2023-01-01 Ervin Cabrera Mendez ervincabrera89@gmail.com Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Ervin Cabrera Mendez ervincabrera89@gmail.com Owner Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed
2049 2024-02-16 09:19 Anonymous (not verified) 94.188.205.169 Cadona Construction LLC Limited Liability Company 215 S Leonard, Sioux City, IA 51103 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-16 Luis Cardona luiscardona5151@gmail.com Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Luis Cardona luiscardona5151@gmail.com Owner Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed
281 2020-10-20 08:58 Anonymous (not verified) 136.37.174.39 Merge Midwest Engineering, LLC Limited Liability Company 2668 W Catalpa Street, Olathe, KS 66061 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-20 Michael Lee Baer lbaer@mergemidwest.com Louisburg Miami Kansas Heather Lee Baer Ami Bowes Signed (1) The employer does not elect the employers’ liability coverage. Janelle Marie Clayton jclayton@mergemidwest.com Self Olathe Johnson Kansas Patrick McCartney David Jahner Signed
1721 2023-07-06 08:19 Anonymous (not verified) 94.188.207.228 Bradford Alexander Carr Proprietorship 3349 Southgate Ct SW Ste 101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-06 Bradford Alexander Carr alex.carr@thrivent.com Coralville Johnson Iowa Gaylon Heetland David King Signed (1) The employer does not elect the employers’ liability coverage. Bradford Alexander Carr alex.carr@thrivent.com Self Coralville Johnson Iowa Gaylon Heetland David King Signed
76 2020-02-24 15:05 Anonymous (not verified) 97.64.133.18 Sky Roofing Partnership 1332 Idaho St., Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Angel Jurado Liberty21424@gmail.com des moines Polk Iowa Valerie Cramer David Murray Signed (1) The employer does not elect the employers’ liability coverage. Cramer Law PLC cramerlaw@halousa.com Attorney Polk Polk Iowa Sara Mc Ginnis David Murray Signed
1791 2023-08-08 15:22 Anonymous (not verified) 94.188.207.227 dutch meadows lawn care Limited Liability Company 304 W 9TH ST. 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. 2023-08-08 david nunnikhoven djnunnik@iowatelecom.net newton Iowa United States david nunnikhoven david nunnikhoven Signed (1) The employer does not elect the employers’ liability coverage. david nunnikhoven djnunnik@iowatelecom.net owner newton Iowa United States david nunnikhoven david nunnikhoven Signed
1455 2023-02-15 11:44 Anonymous (not verified) 94.188.205.177 Bruce A. Nelson Proprietorship 300 Shetland Dr Nw Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Bruce A. Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Lynn M Haigh David Reibsamen Signed (1) The employer does not elect the employers’ liability coverage. Sheryl Nelson sherylnelson15@yahoo.com Wife Cedar Rapids Linn Iowa Lynn M. Haigh David Reibsamen Signed
1142 2022-06-03 21:35 Anonymous (not verified) 66.43.196.246 Doug ayers Proprietorship 808 Willow st Dumont Iowa 50625 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-03 Doug dale ayers dougayers2612@gmail.com Dumont Butler Iowa Amy Pcha David Shear Signed (1) The employer does not elect the employers’ liability coverage. Doug ayers dougayers2612@gmail.com Owner operator Dumont Butler Iowa Amy Picha David Shear Signed
1815 2023-08-23 14:16 Anonymous (not verified) 94.188.207.228 JP Distribution, LLC Limited Liability Company 3738 Pine Rdg 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. 2023-08-23 Jared Prelle jpdist2014@gmail.com North Liberty IA United States Linda Stien Dawn Franck Signed (1) The employer does not elect the employers’ liability coverage. Jared Prelle jpdist2014@gmail.com Owner North Liberty Johnson IA Linda Stien Dawn Franck Signed
266 2020-09-21 18:08 Anonymous (not verified) 174.126.94.77 Club Fantasy Inc. Limited Liability Company P.O. Box 5115 Sioux City Iowa 51102 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-21 Curtis A. Behr cacbehr@aol.com Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed (1) The employer does not elect the employers’ liability coverage. Curtis A. Behr cacbehr@aol.com Self Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed
1183 2022-07-06 13:43 Anonymous (not verified) 50.82.95.247 2DL Construction, LLC Limited Liability Company 1134 21st Street, Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-06 Diego Lopez calihernandez01@icloud.com Des Moines Polk Iowa Ryan Johnson Deanna Yersin Signed (1) The employer does not elect the employers’ liability coverage. Diego Lopez calihernandez01@icloud.com Self Des Moines Polk Iowa Ryan Johnson Deanna Yersin Signed
1290 2022-09-01 15:29 Anonymous (not verified) 198.14.221.176 DR. WAYNE HAIDSIAK ii and Dr. Junior Hensley DBA Tri County Veterinary Service Partnership 101 170TH ST CLEARFIELD IA 50840 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-01 Dr. Wayne Haidsiak II insurance@ringgoldins.com Lenox Taylor IA Amy Ford Deb Davenport Signed (1) The employer does not elect the employers’ liability coverage. Dr. J.D. Hensley insurance@ringgoldins.com Partner Cleafield Taylor IA Amy Ford Deb Davenport Signed
1655 2023-05-19 14:19 Anonymous (not verified) 94.188.207.229 Cutting Edge Concrete LLC Limited Liability Company 325 Linn St, Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-19 Joel Waltz joel@cuttingedgeiowa.com Boone Boone Iowa Robert Simmons Deb Ernst Signed (1) The employer does not elect the employers’ liability coverage. Joel Waltz joel@cuttingedgeiowa.com Self Boone Boone IA Robert Simmons Deb Ernst Signed
340 2020-12-18 08:37 Anonymous (not verified) 172.83.31.129 Todd Fisher DBA Lake Country Window Cleaning Proprietorship 1506 Willow Place, Clear Lake, IA 50428 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-12-18 Todd Fisher Lakecountrywindow@yahoo.com Clear Lake Cerro Gordo Iowa Matt Koch Deb Koch Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Todd Fisher lakecountrywindow@yahoo.com Same Clear Lake Cerro Gordo Iowa Matt Koch Deb Koch Signed
912 2022-02-14 17:51 Anonymous (not verified) 72.168.160.122 Mark Weiss Proprietorship 11461 NW Timber Way Granger Iowa 50109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-14 Mark Weiss kkweiss77@yahoo.com Granger Polk Iowa Paul Ness Deb Ness Signed (1) The employer does not elect the employers’ liability coverage. Casi Sparks csparks@destinyhomesusa.com Subcontractor Waukee Dallas Iowa Paul Ness Deb Ness Signed
2065 2024-02-29 13:53 Anonymous (not verified) 94.188.205.166 LEONARD BOUGHTON Partnership 1616 AGENCY ST, BURLINGTON, IOWA 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 LEONARD L BOUGHTON firstrate96@yahoo.com BURLINGTON DES MOINES IOWA PAM ZIPPE DEB SCOTT Signed (1) The employer does not elect the employers’ liability coverage. LEONARD L BOUGHTON firstrate96@yahoo.com Owner BURLINGTON DES MOINES IOWA PAM ZIPPE DEB SCOTT Signed
1741 2023-07-12 09:38 Anonymous (not verified) 94.188.207.230 Jose Tavares Proprietorship 1175 Office Park Road Apt 109 WDM IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-28 Jose Tavares deb@piciowa.com WDM Polk IA Martin Pin on Deb Stratton Signed (1) The employer does not elect the employers’ liability coverage. Jose Tavares deb@piciowa.com self WDM Polk IA Martin Pinon Deb Stratton Signed
310 2020-11-09 13:32 Anonymous (not verified) 75.89.78.93 CA Smith LLC Limited Liability Company 805 N Hayes Street Mount Ayr, Iowa 50854 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 CA Smith LLC smithoil.cs@gmail.com Mount Ayr Ringgold Iowa Wm H French Deborah Creveling Signed (1) The employer does not elect the employers’ liability coverage. CA Smith LLC smithoil.cs@gmail.com Self Mount Ayr Ringgold Iowa Wm H French Deborah Creveling Signed
262 2020-09-18 13:54 Anonymous (not verified) 75.162.229.152 Morgan Group LLC Limited Liability Company 1124 7th 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. 2020-09-18 Mackinley Charles Morgan MORGANGROUPLLC@GMAIL.COM West Des Moines Polk Iowa Mark Steven Morgan Deborah Renee Morgan Signed (1) The employer does not elect the employers’ liability coverage. Mackinley Charles Morgan MorganGroupLLC@gmail.com Owner of Company West Des Moines Polk Iowa Mark Steven Morgan Deborah Renee Morgan Signed
1798 2023-08-14 12:16 Anonymous (not verified) 94.188.207.223 David Robles Proprietorship 3912 E 23rd St Des Moines, Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-09 David Robles deb@piciowa.com Des Moines Polk Iowa Debra E Stratton Kelly K Denger Signed (1) The employer does not elect the employers’ liability coverage. David Robles deb@piciowa.com self Des Moines Polk Iowa Kelly K Denger Debra E Stratton Signed
2153 2024-04-15 21:59 Anonymous (not verified) 94.188.205.167 Ethan M Hoffman Proprietorship 1442 N. County RD 800, Hamilton, IL 62341 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Ethan M Hoffman kellylanz1967@gmail.com Hamilton IL United States Gay Hoffman Debra Kelley Signed (1) The employer does not elect the employers’ liability coverage. Ethan M Hoffman kellylanz1967@gmail.com Self Hamilton IL United States Gay Hoffman Debra Kelley Signed
661 2021-10-01 09:00 Anonymous (not verified) 71.34.184.201 Jose Tavares Proprietorship 1175 Office Park Rd Apt 109 WDM IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-24 Jose Tavares deb@piciowa.com 1175 Office Park Rd Apt 109 WDM IA 50266 Polk Iowa Martin Pinon Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Jose Tavares deb@piciowa.com self WDM Polk IA Martin Pinon Debra Stratton Signed
1632 2023-05-09 11:10 Anonymous (not verified) 94.188.205.177 MM Drywall LLC Moises Melo Santiago Proprietorship 7500 Bloomfield Road Lot 78 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-01 Moises Melo Santiago deb@piciowa.com Des Moines Polk Iowa kelly Denger Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. MM Drywall LLC Moises Melo Santiago deb@piciowa.com self Des Moines polk Iowa Kelly Denger Debra Stratton Signed
1692 2023-06-15 15:20 Anonymous (not verified) 94.188.207.228 Javier Rodriguez Proprietorship 1512 18th St Des Moines, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Javier A Rodriguez R.Javier14@gmail.com Des Moines Polk Iowa Kelly Denger Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Javier A Rodriguez R.Javier14@gmail.com self Des Moines Polk Iowa Kelly Denger Debra Stratton Signed
1980 2024-01-10 11:32 Anonymous (not verified) 94.188.207.224 Raudel Correa Proprietorship 1924 23rd 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. 2024-01-02 Raudel Correa deb@piciowa.com Des Moines Polk Iowa Martin Pinon Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Raudel Correa deb@piciowa.com self Des Moines Polk Iowa Martin Pinon Debra Stratton Signed
616 2021-08-23 13:14 Anonymous (not verified) 173.25.153.19 Levon Proprietorship 210 S 41st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-23 Levon shheba sheebalevon@gmail.com West des Moines IA 50265 Polk county IA Alina sheeba Delon sheeba Signed (1) The employer does not elect the employers’ liability coverage. Levon sheeba sheebalevon@gmail.com Myself West des Moines IA 50265 Polk county IA Alina sheeba Delon sheeba Signed
417 2021-03-03 13:49 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Lance Jeffrey Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Abby Glendenning accounting@lynxag.com Officer Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
418 2021-03-03 13:50 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Abigail Jayne Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
419 2021-03-03 13:52 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Tamara Glendenning lanceandabby@wccta.net Davis Junction Ogle Illinois Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
420 2021-03-03 13:53 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Terry Scott Glendenning lanceandabby@wccta.net Davis Junction Ogle Illinois Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
1896 2023-11-03 14:23 Anonymous (not verified) 94.188.207.225 Shane Adams Limited Liability Company 3944 54th st Des Moines,IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 Shane Steven Adams Shane6079@gmail.com Des Moines Polk Iowa Justin Mace Denice Sutton Signed (1) The employer does not elect the employers’ liability coverage. Shane Adams Shane6079@gmail.com Owner Des Moines Polk Iowa Justin Mace Denice Sutton Signed
1291 2022-09-02 13:24 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC Limited Liability Company 1107 Pheasant Valley St, Iowa City, IA 52246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-02 Nicole Keck niccikeckllc@gmail.com Iowa City Iowa United States Evangeline Kadera Denise Kandel Signed (1) The employer does not elect the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
1292 2022-09-02 13:26 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC Limited Liability Company 1107 Pheasant Valley St, Iowa City, IA 52246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-02 Benjamin Darbro darbrob@gmail.com Iowa City Iowa United States Evangeline Kadera Denise Kandel Signed (1) The employer does not elect the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
576 2021-07-14 18:13 Anonymous (not verified) 69.169.10.40 J&M Excavation Inc. Limited Liability Company 411 Pine Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-14 Bruce Bilyeu jmexcavation@outlook.com Norwalk Warren IA Mike Petersen Dennis Bilyeu Signed (1) The employer does not elect the employers’ liability coverage. Bruce Bilyeu jmexcavation@outlook.com Owner Norwalk Warren IA Mike Petersen Dennis Bilyeu Signed
1916 2023-11-21 12:31 Anonymous (not verified) 94.188.205.174 DC Painting Proprietorship 205 Astor St, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 Damion Clement gcort06@gmail.com Des Moines Polk IA Brandi Haight Dennis Clement Signed (1) The employer does not elect the employers’ liability coverage. Damion Clement gcort06@gmail.com Owner 205 Astor Street Polk IA Brandi Haight Dennis Clement Signed
1133 2022-05-29 12:39 Anonymous (not verified) 75.162.116.31 Thompson Trades Limited Liability Company 3371 200th 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. 2022-05-29 shane thompson shane@thompsontrades.net prole IA IA Rebecca Thompson Denyse Thompson Signed (1) The employer does not elect the employers’ liability coverage. shane thompson shane@thompsontrades.net owner prole IA IA Rebecca Ann Thompson Denyse Rae Thompson Signed
1606 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
1607 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
1608 2023-04-26 11:51 Anonymous (not verified) 94.188.205.167 Jesus Lozano Proprietorship 1334 E 16th st Des Moines Iowa 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-26 Jesus Lozano Jesuslozano0086@icloud.com Des Moines Polk Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Jesus Lozano Jesuslozano0086@icloud.com Owner Des Moines Polk Iowa Sheanah Wright Derek Mullins Signed
1609 2023-04-26 11:58 Anonymous (not verified) 94.188.205.168 edwin gonzalez Proprietorship 115 e ayers st osceola ia 50213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 edwin gonzalez lrestrada83@gmail.com osceola Clark ia Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. edwin gonzalez lrestrada83@gmail.com owner osceola clarke ia Sheanah Wright Derek Mullins Signed
1610 2023-04-26 12:03 Anonymous (not verified) 94.188.205.175 Thomas J Mullins Proprietorship 6569 Vista Dr. West Des Moines, IA. 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Thomas J Mullins mullinsthomasj@gmail.com West Des Moines Dallas IA Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Thomas J Mullins mullinsthomasj@gmail.com Self West Des Moines Dallas IA Sheanah Wright Derek Mullins Signed
1895 2023-11-03 12:21 Anonymous (not verified) 94.188.207.227 Oxbo LLC Limited Liability Company 2528 Evergreen Ave. Red Oak, IA 51566 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 Mettra Sperling sperlingrose66@gmail.com Red Oak Montgomery IA Chantal Sperling Derek Penry Signed (1) The employer does not elect the employers’ liability coverage. Mettra Sperling sperlingrose66@gmail.com Self Red Oak Montgomery IA Chantal Sperling Derek Penry Signed
1058 2022-04-19 13:19 Anonymous (not verified) 50.83.154.192 Property Maintenance Services of Iowa LLC Limited Liability Company PO Box 166 Low Moor IA 52757 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-19 Frederick Stewart curlyfry42000@yahoo.com LOW MOOR IA United States Irene R Stewart Derek S Jensen Signed (1) The employer does not elect the employers’ liability coverage. Frederick Lee Stewart zombiesby2012@gmail.com Owner Clinton IA United States Irene R Stewart Derek S Jensen Signed
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
1409 2023-01-05 11:55 Anonymous (not verified) 173.23.88.7 Top tier gutter systems llc Limited Liability Company 405a 1st Ave sw Cedar Rapids, 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. 2023-01-05 Rocky layne smith toptierguttersystems@yahoo.com Cedar Rapids Linn IA Faye momodu Rocky smith Signed (1) The employer does not elect the employers’ liability coverage. Rocky smith toptierguttersystems@yahoo.com Self Cedar Rapids Linn IA Faye momodu Derrick Signed
578 2021-07-16 15:26 Anonymous (not verified) 184.80.177.137 Scotty's Appliance & TV, LLC Limited Liability Company 529 5th St NW - Dyersville, IA 52040 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-16 Sandra Krogman jheims@english-insurance.com Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
638 2021-09-13 09:18 Anonymous (not verified) 74.84.91.178 Thomas Tremble Proprietorship 1209 University Avenue, Dubuque, IA 52001 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-09 Thomas Tremble TJTremble21@gmail.com Dubuque Dubuque Iowa Gabe Drewelow Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Thomas Tremble TJTremble21@gmail.com self Dubuque Dubuque Iowa Gabe Drewelow Derrick Parsons Signed
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
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
1004 2022-03-23 15:01 Anonymous (not verified) 104.201.110.2 Ryan Fischer Proprietorship 809 8th St Sw I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Ryan Fischer rfischer@phillipsstaffod.com Des Moines Polk IA Josh Stafford Desiree Dennis Signed (1) The employer does not elect the employers’ liability coverage. Ryan Fischer rfischer@phillipsstafford.com Self DES MOINES IA United States Josh Stafford Desiree Dennis Signed
271 2020-09-27 20:30 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping Inc Limited Liability Company 5235 Jennifer Dr 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. 2020-09-27 William E Hutchinson Jr btnwhutch@aol.com Pleasant Hill Polk Iowa Tracy Hutchinson Diana Benda Signed (1) The employer does not elect the employers’ liability coverage. William E Hutchinson Jr btnwhutch@aol.com Self Pleasant Hill Polk Iowa Tracy Hutchinson Diana Benda Signed
317 2020-11-15 19:20 Anonymous (not verified) 172.58.83.192 All Cut Lawn Care Proprietorship 3506 Glover Ave. Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-15 Michael D Money michaelmoney883@gmail.com Des Moines Polk Iowa Deanna L Phagan Diana J Jennings Signed (1) The employer does not elect the employers’ liability coverage. Michael D Money michaelmoney883@gmail.com Myself Des Moines Polk Iowa Deanna L Phagan Diana J Jennings Signed
1695 2023-06-19 06:54 Anonymous (not verified) 94.188.207.224 Leaf Filter Proprietorship 3060 SE Grimes Blvd Unit 100 Grimes, IA 50111 United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-17 Trenton Finch tjfinch10@gmail.com Kellogg Jasper Iowa Teagan Kruse Diane Finch Signed (1) The employer does not elect the employers’ liability coverage. Trenton Finch tjfinch10@gmail.com Subcontractor Kellogg Jasper Iowa Teagan Kruse Diane Finch Signed
295 2020-10-28 15:19 Anonymous (not verified) 72.46.55.242 SAI'S RENTALS LLC Limited Liability Company 637 S ANKENY BLVD, 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. 2020-10-28 SUMEET SEHGAL saisrentals.avisbudget@gmail.com ANKENY, IA POLK IOWA CLINT LILIENTHAL DIANNE KELLE Signed (1) The employer does not elect the employers’ liability coverage. SUMEET SEHGAL saisrentals.avisbudget@gmail.com SELF ANKENY POLK IOWA CLINT LILIENTHAL DIANNE KELLE Signed
1830 2023-09-08 11:45 Anonymous (not verified) 94.188.205.177 Bradley A Sneeden Proprietorship 36 Sunset Drive, Beardstown, IL 62618 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-08 Bradley A Sneeden bradsneeden@gmail.com Beardstown Cass IL Billie Sneeden Dillon McNeff Signed (1) The employer does not elect the employers’ liability coverage. Bradley A Sneeden bradsneeden@gmail.com Self Beardstown Cass IL Billie Sneeden Dillon McNeff Signed
1530 2023-03-23 16:14 Anonymous (not verified) 94.188.205.166 Los Cousins gutters Limited Liability Company 901 sw 62nd st des moines ia 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-23 Freddy Morales 1981ayoria@gmail.com Des Moines Ia Polk Iowa Denni bazan Dionicio morales Signed (1) The employer does not elect the employers’ liability coverage. Freddy Morales 1981ayoria@gmail.com 1981ayoria@gmail.com Desmoines Polk Ia Dennis Bazan Dionicio Morales Signed
500 2021-04-29 13:09 Anonymous (not verified) 204.155.61.217 JWJ Home Remodeling LLC Limited Liability Company 16915 Weaver Lake Dr, Maple Grove MN 55311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-29 Jackson Janzen jacksonjanzen@hailmayday.com Maple Grove hennepin MN Ashley Kraft DocuSign Signed (1) The employer does not elect the employers’ liability coverage. Jackson Janzen jacksonjanzen@hailmayday.com Owner Maple Grove Hennepin MN Ashley Kraft DocuSign Signed
305 2020-11-02 08:40 Anonymous (not verified) 204.124.192.31 JPS Framing Proprietorship 102 WALL AVE - DES MOINES IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-02 JACKELYN SANCHEZ JPSFRAMING629@GMAIL.COM DES MOINES POLK IOWA ROGELIO SANCHEZ DOMINIQUE SANCHEZ Signed (1) The employer does not elect the employers’ liability coverage. JUAN SERRANO JPSFRAMING629@GMAIL.COM EMPLOYER DES MOINES POLK IOWA ROGELIO SANCHEZ DOMINIQUE SANCHEZ Signed
193 2020-06-24 11:13 Anonymous (not verified) 173.28.196.82 Gray Nation LLC DBA Gray Goat Tattoo Limited Liability Company 116 N 1st Street West Branch, Iowa 52358-9663 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. 2020-06-24 Elizabeth Gray beth.gray516@gmail.com West Branch Cedar Iowa Luis Ordenana Don Naugthon Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Elizabeth Gray beth.gray516@gmail.com LLC Member West Branch Cedar Iowa Luis Ordenana Don Naughton Signed
1014 2022-03-28 16:33 Anonymous (not verified) 76.102.203.170 Self - Maryssa Wanlass Proprietorship 871 Wood St. Oakland CA 94607 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-01 Maryssa Wanlass maryssa.wanlass@alli-center.com Oakland Alameda California Mark Vashro Don Naughton Signed (1) The employer does not elect the employers’ liability coverage. Maryssa Wanlass maryssa.wanlass@alli-center.com Self Oakland Alameda California Mark Vashro Don Naughton Signed
226 2020-08-07 11:37 Anonymous (not verified) 71.39.227.238 Clinton Luellen Proprietorship 18591 N Ave, Minburn, IA 50167 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-07 Clinton Luellen CALuellen@gmail.com Minburn Dallas Iowa Winette Luellen Don Richardson Signed (1) The employer does not elect the employers’ liability coverage. Clinton Luellen CALuellen@gmail.com Self Minburn Dallas Iowa Winette Luellen Don Richardson Signed
1327 2022-10-06 12:23 Anonymous (not verified) 71.39.227.238 RICK OBEREMBT Proprietorship 1702 SYCAMORE ST, DALLAS CNETER, 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. 2022-10-05 RICK OBEREMBT werock83@gmail.com DALLAS CENTER DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed (1) The employer does not elect the employers’ liability coverage. RICK OBEREMBT werock83@gmail.com SELF DALLAS CENTER DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed
1335 2022-10-17 11:32 Anonymous (not verified) 71.39.227.238 PELZER AG LLC Limited Liability Company 16864 280TH ST, REDFIELD, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-17 MATT PELZER MPELZERFARMS@GMAIL.COM REDFIELD DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed (1) The employer does not elect the employers’ liability coverage. MATT PELZER MPELZERFARMS@GMAIL.COM PRESIDENT REDFIELD DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed
949 2022-03-04 16:09 Anonymous (not verified) 173.20.147.171 Duwa Waterproofing LLC Limited Liability Company 729 Deer view Ave, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-04 Stacy Duwa duwawaterproofing@gmail.com Tiffin Johnson Iowa Lauren Obermann Don Vittetoe Signed (1) The employer does not elect the employers’ liability coverage. Stacy Duwa duwawaterproofing@gmail.com owner Tiffin Johnson Iowa Lauren Obermann Don Vittetoe Signed
39 2020-01-19 11:00 Anonymous (not verified) 75.163.84.145 Allen L Bryen Proprietorship 2609 Madison St Bellevue NE 68005 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-19 Allen Lee Bryen Allen.Bryen@yahoo.com Bellevue Sarpy Nebraska Jeffrey Coats Donald Coats Signed (1) The employer does not elect the employers’ liability coverage. Allen L Bryen Allen.Bryen@yahoo.com Self Bellevue Sarpy Nebraska jeffrey Coats Donald Coats Signed
1085 2022-05-03 10:38 Anonymous (not verified) 65.144.174.26 Caleb Schroeder Proprietorship 4051 SW 56th St Des Moines, IA 50321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-03 Caleb Schroeder calebpschroeder@gmail.com Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed (1) The employer does not elect the employers’ liability coverage. Caleb Schroeder calebpschroeder@gmail.com Self Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed
126 2020-04-21 21:19 Anonymous (not verified) 69.76.135.87 Merge Midwest Engineering, LLC Limited Liability Company 2668 W. Catalpa 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. 2020-04-21 Mark Daniel Stuempel mstuempel@mergemidwest.com Kansas City Wyandotte KANSAS Anna Langer Donna Stuempel Signed (1) The employer does not elect the employers’ liability coverage. Janelle Clayton jclayton@mergemidwest.com LLC Member Olathe Johnson KS Anna Langer Donna Stuempel Signed
1053 2022-04-14 21:08 Anonymous (not verified) 50.83.192.136 John E Snyder JR Proprietorship 1677 PACIFIC ST, MURRAY, IA 50174 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 John Snyder JR jrsweldingia@gmail.com MURRAY Clarke Iowa Shelly Goslar Dorene Short Signed (1) The employer does not elect the employers’ liability coverage. John Snyder JR jrsweldingia@gmail.com Selg MURRAY Clarke Iowa Shelly Goslar Dorene Short Signed
843 2022-01-20 07:48 Anonymous (not verified) 207.199.230.75 Heart of Iowa Inspections LLC Limited Liability Company 2700 Highway 63 Oskaloosa, Iowa 52577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-20 Randy DeHeer rdenheer2828@gmail.com Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed (1) The employer does not elect the employers’ liability coverage. Randy DeHeer rdenheer2828@gmail.com self Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed
934 2022-02-23 12:13 Anonymous (not verified) 207.199.230.75 Randy DeHeer Limited Liability Company 2700 Highway 63 Oskaloosa, Iowa 52577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-23 Randy DeHeer rdeheer2828@gmail.com Oskaloosa Mahaska Jowa Cheryl Brown Doris Crile Signed (1) The employer does not elect the employers’ liability coverage. Randy DeHeer rdeheer2828@gmail.com Self Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed
932 2022-02-22 17:20 Anonymous (not verified) 72.212.49.250 Duane Bruxvoort Proprietorship 201 Park Lane, Pella, IA 50219 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-01 Duane L Bruxvoort duanebrux@gmail.com Pella Marion Iowa Megan Lee Pingel Dorothy Jean Bruxvoort Signed (1) The employer does not elect the employers’ liability coverage. Duane Bruxvoort duanebrux@gmail.com Self Pella Marion Iowa Megan Lee Pingel Dorothy Bruxvoort 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
1215 2022-07-20 13:43 Anonymous (not verified) 173.21.133.45 Ottumwa mow & snow LLC Limited Liability Company 11443 Bladensburg Rd. 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. 2022-07-20 Lucia A Hughes lucyh68313@gmail.com Ottumwa Wapello Iowa Katy Knott Doug Knott Signed (1) The employer does not elect the employers’ liability coverage. RJ Hallman rjhallman@fedins.com Insurance Owatonna Steele Minnesota Katy Knott Doug Knott Signed
1220 2022-07-21 13:12 Anonymous (not verified) 172.58.83.160 Ottumwa mow & snow LLC Limited Liability Company 11443 Bladensburg Rd. 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. 2022-07-21 María Duarte mariacabrera515@icloud.com Ottumwa Wapello Iowa Katy Knott Doug Knott Signed (1) The employer does not elect the employers’ liability coverage. RJ Hallman rjhallman@fedins.com Insurance Owatonna Steele Minnesota Katy Knott Doug Knott Signed
1225 2022-07-23 18:01 Anonymous (not verified) 174.242.224.34 Ottumwa mow & snow llc Limited Liability Company 11443 Bladensburg Rd 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. 2022-07-23 JoAnn laBella joannlabella@gmail.com Ottumwa Wapello IA Doug Knott Katy Knott Signed (1) The employer does not elect the employers’ liability coverage. RJ Hallman rjhallman@fedins.com Insurance Owatonna Steele MN Katy knott Doug knott Signed
1226 2022-07-23 18:02 Anonymous (not verified) 174.242.224.34 Ottumwa mow & snow llc Limited Liability Company 11443 Bladensburg Rd 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. 2022-07-23 JoAnn laBella joannlabella@gmail.com Ottumwa Wapello IA Doug Knott Katy Knott Signed (1) The employer does not elect the employers’ liability coverage. RJ Hallman rjhallman@fedins.com Insurance Owatonna Steele MN Katy knott Doug knott Signed
752 2021-11-17 08:22 Anonymous (not verified) 166.181.82.81 Michael sprout Limited Liability Company 1208 N THORNWOOD AVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-14 Michael Sprout 1293newhome@gmail.com Davenport IA IA Mike smith Doug palmer Signed (1) The employer does not elect the employers’ liability coverage. Michael Sprout 1293newhome@gmail.com Geico Davenport IA IA Mike smith Doug palmer Signed
511 2021-05-10 17:53 Anonymous (not verified) 173.24.231.27 QSC Snow Removal Proprietorship 1211 Carroll Boone IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Vincent A Kaylor phenox32@gmail.com Boone IA United States Lori Harvey Doug Robertson Signed (1) The employer does not elect the employers’ liability coverage. Vincent A Kaylor phenox32@gmail.com self Boone IA United States Lori Harvey Doug Robertson Signed
1799 2023-08-14 14:42 Anonymous (not verified) 94.188.205.174 Magiclean Proprietorship 2001 S. 16th Burlington Iowa 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-14 Sydney Bornsheuer Mistycale@gmail.com Burlington Iowa Iowa Dustina Fenton Doug Shupick Signed (1) The employer does not elect the employers’ liability coverage. Misty Cale magicleanburlington@gmail.com Owner Burlington Des Moines Iowa Dustina Fenton Doug Shupick 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
948 2022-03-04 13:23 Anonymous (not verified) 71.28.216.129 Zack & Rachael Bushman Proprietorship 321 Countryside Dr, Waukon, IA 52172 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-04 Rachael Bushman rachaelnessa@yahoo.com Waukon Allamakee IA Zack Bushman Doyle Wegner Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Zack Bushman rachaelnessa@yahoo.com Owner Operator Waukon Allamakee IA Rachael Bushman Doyle Wegner Signed
2089 2024-03-12 10:58 Anonymous (not verified) 94.188.205.166 Margarito R Guzman Proprietorship 4512 S 22nd ST Omaha NE 68107 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Margarito R Guzman abrahamguzman030@gmail.com omaha douglas NE jose abraham guzman garcia Drakkar Rapaich Signed (1) The employer does not elect the employers’ liability coverage. Margarito Guzman abrahamguzman030@gmail.com Owner Omaha Douglas Nebraksa jose abraham guzman garcia Drakkar Rapaich Signed
821 2022-01-04 10:06 Anonymous (not verified) 173.18.4.60 Levi Walker Proprietorship 601 N 10th Avenue Winterset, Iowa 50273 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-04 Levi Walker walker.lw31@gmail.com Winterset Madison Iowa Morgan Walker Drew Van Laar Signed (1) The employer does not elect the employers’ liability coverage. Levi Walker walker.lw31@gmail.com self Winterset Madison Iowa Morgan Walker Drew Van Laar Signed
646 2021-09-20 08:54 Anonymous (not verified) 173.24.107.209 QCA Professional Contractors Limited Liability Company 3314 67th Ave, Moline, IL. 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-20 Allan Celada allancelada@qcaprocontractors.com Moline Rock Island IL Alexander Celada Drexel Miller Signed (1) The employer does not elect the employers’ liability coverage. Allan Celada allancelada@qcaprocontractors.com self Moline Rock Island IL Alexander Celada Drexel Miller Signed
1897 2023-11-06 09:12 Anonymous (not verified) 94.188.205.177 Matthew Jones Limited Liability Company 124 NE 49th 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. 2023-11-06 Matthew Jones mjj4242@gmail.com Ankeny Polk IA Duan Willform AJ Giebelstein Signed (1) The employer does not elect the employers’ liability coverage. Matthew Jones mjj4242@gmail.com Self Ankeny Polk IA AJ Giebelstein Duan Willform Signed
592 2021-07-29 16:44 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Adam Reth adam@choiceagservices.com Manchester IA United States Josh Soppe Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Adam Reth adam@choiceagservices.com Owner Manchester Delaware Iowa Josh Soppe Dustin Fessler Signed
1622 2023-05-01 16:05 Anonymous (not verified) 94.188.205.174 Danny Shineflew Proprietorship 103th 10street West Des Moines I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-01 Danny Shineflew dannyshineflew@gmail.com West Des Moines Polk Iowa Tony Ekman Dustin Hogan Signed (1) The employer does not elect the employers’ liability coverage. Danny Shineflew dannyshineflew@gmail.com self West Des Moines Polk Iowa Tony Ekman Dustin Hogan Signed
1207 2022-07-15 10:02 Anonymous (not verified) 75.89.78.50 A&J Remodeling LLC Limited Liability Company 2 Bungalow Ct Newton, Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-15 Austin Hudson ahudson7536@gmail.com Newton Jasper IA Liz Allen Dustin Ingram Signed (1) The employer does not elect the employers’ liability coverage. Austin Hudson anjremodel@gmail.com Co-owner Newton Jasper IA Liz Allen Dustin Ingram Signed
626 2021-08-31 11:39 Anonymous (not verified) 166.181.81.253 Birds landscape maintenance LLC Limited Liability Company 1307 w 4th st south I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-31 Michael Alan bird birdslawn@hotmail.com Newton Jasper Iowa Jeff Dennis carder Dustin James bos Signed (1) The employer does not elect the employers’ liability coverage. Michael Alan bird birdslawn@hotmail.com Same - owner Newton Jasper Iowa Jeff Dennis carder Dustin James bos Signed
709 2021-11-04 12:38 Anonymous (not verified) 50.83.182.182 All Pro Painting LLC Limited Liability Company 5431 Gear Street Prole 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. 2020-11-04 Tory Webb (United Trades Group LLC) toryw@unitedtradesgroup.org Norwalk Warren Iowa Ryan Drabek Dustin Kohler Signed (1) The employer does not elect the employers’ liability coverage. Adam Adams adam@allpropaintingdsm.com Project Manager Prole Warren Iowa Ryan Drabek Dustin Kohler Signed
710 2021-11-04 12:57 Anonymous (not verified) 50.83.182.182 United Trades Group LLC Limited Liability Company 4813 Candlewick Drive Norwalk Iowa 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-04 Tory Webb torywebbdmi@gmail.com Norwalk Polk Iowa Ryan Drabek Dustin Kohler Signed (1) The employer does not elect the employers’ liability coverage. Tory Webb toryw@unitedtradesgroup.org Owner, Management Norwalk Iowa United States Ryan Drabek Dustin Kohler Signed
732 2021-11-09 15:25 Anonymous (not verified) 50.83.182.182 United Trades Group LLC Limited Liability Company 4813 Candlewick 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. 2021-11-09 Ryan Drabek ryand@unitedtradesgroup.org Des Moines Polk Iowa Dustin Kohler Trevor Spidle Signed (1) The employer does not elect the employers’ liability coverage. Tory Webb toryw@unitedtradesgroup.org Owner, Management Norwalk Warren Iowa Trevor Spidle Dustin Kohler Signed
273 2020-10-05 13:57 Anonymous (not verified) 173.30.54.139 Jackson Exteriors Proprietorship 705 Cherry Avenue Woodward,ia 50276 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-05 Lucas Jackson ljajackson41977@gmail.com Woodward IA United States Cody Roth Dustin Perry Signed (1) The employer does not elect the employers’ liability coverage. Lucas Jackson ljajackson41977@gmail.com Owner Woodward Dallas United States Cody Roth Dustin perry Signed
127 2020-04-24 09:18 Anonymous (not verified) 63.152.82.5 TD Auto Services LLC Limited Liability Company 451 W Parker St Waterloo IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-27 Dakoda Sellers dakoda.d.sellers@gmail.com Waverly Bremer IA Jennie Roster Dustin Roster Signed (1) The employer does not elect the employers’ liability coverage. Dakoda D Sellers dakoda.d.sellers@gmail.com Owner Waverly Bremer IA Jennie Roster Dustin Roster Signed
1299 2022-09-07 14:55 Anonymous (not verified) 167.142.60.66 Harleen Trenching Proprietorship 2066 X Ave, Madrid Iowa 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Bill Harleen sandyharleen@hotmail.com Madrid Boone Iowa Thomas H Andersen Dustin T Andersen Signed (1) The employer does not elect the employers’ liability coverage. Bill Harleen Harleentrenching@hotmail.com Self Madrid Boone Iowa Thomas H Andersen Dustin T Andersen Signed
533 2021-06-03 20:37 Anonymous (not verified) 75.162.171.128 KP Repair LLC Limited Liability Company 719 10th St. NE Mason City, Iowa. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-03 Alexander Wessels kprepair@outlook.com MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed (1) The employer does not elect the employers’ liability coverage. Alexander Wessels kprepair@outlook.com Owner MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed
64 2020-02-18 10:02 Anonymous (not verified) 198.167.182.164 Elite Electrical Service LLC Limited Liability Company 2035 Lynncrest Dr, Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 Sean Brogan brogan_sean@hotmail.com Coralville Johnson Iowa Kyle Stahle Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Sean Brogan brogan_sean@hotmail.com Managing Member Coralville Johnson Iowa Kyle Stahle Dyan Kriener Signed
67 2020-02-19 10:16 Anonymous (not verified) 198.167.182.164 AWF579 LLC Limited Liability Company 13 Lynden Dr NE, Iowa City, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 Jeffrey Schiltz jeffschiltz2@yahoo.com Iowa City Johnson Iowa Kyle Stahle Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Schiltz jeffschiltz2@yahoo.com Managing Member Iowa City Johnson Iowa Kyle Stahle Dyan Kriener Signed
85 2020-03-09 08:17 Anonymous (not verified) 198.167.182.164 Simply Anchored LLC dba Simply Mae's Limited Liability Company 601 Broad St, Story City, IA 50248 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Jessi Kettenacker jessi@simplymaes.com Story City Story Iowa Lynn McKinney Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Jessi Kettenacker jessi@simplymaes.com Managing Member Story City Story Iowa Lynn McKinney Dyan Kriener Signed
86 2020-03-09 08:19 Anonymous (not verified) 198.167.182.164 Simply Anchored LLC dba Simply Mae's Limited Liability Company 601 Broad St, Story City, IA 50248 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Cande Coulter cande@simplymaes.com Story City Story Iowa Lynn McKinney Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Candy Coulter cande@simplymaes.com Managing Member Story City Story Iowa Lynn McKinney Dyan Kriener Signed
151 2020-05-07 15:57 Anonymous (not verified) 198.167.182.164 Hawk-I Trucking LLC Limited Liability Company 521 Greenfield Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-06 Chad Lee Freeman ricenogle@southslope.net Tiffin Johnson IA Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Chad Lee Freeman ricenogle@southslope.net Managing Member Tiffin Johnson IA Scott Freeman Dyan Kriener Signed
152 2020-05-11 15:56 Anonymous (not verified) 198.167.182.164 Hawk-I Trucking LLC Limited Liability Company 521 Greenfield Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-11 Tyler Rogers tylerrogersinc@yahoo.com Iowa City Johnson Iowa Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Tyler Rogers tylerrogersinc@yahoo.com Member Iowa City Johnson Iowa Scott Freeman Dyan Kriener Signed
438 2021-03-17 06:52 Anonymous (not verified) 198.167.182.164 David L Ridnour Proprietorship 1415 4th St, 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. 2021-03-16 David L Ridnour dlridnour@gmail.com Perry Dallas Iowa Steve Fishman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. David L Ridnour dlridnour@gmail.com Owner Perry Dallas Iowa Steve Fishman Dyan Kriener Signed
488 2021-04-20 13:42 Anonymous (not verified) 69.63.16.2 STC Construction LLC Limited Liability Company 329 Sycamore St, Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-20 Sean Crane stc0241@gmail.com Riverside Washington Iowa Carol Glass Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Sean Crane stc0241@gmail.com Managing Member Riverside Washingon Iowa Carol Glass Dyan Kriener Signed
489 2021-04-20 13:47 Anonymous (not verified) 69.63.16.2 Mow-n-Mor Lawn & Landscaping LLC Limited Liability Company 2585 500th St SW, 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. 2021-04-19 Robert Sieren mtesdell@yahoo.com Kalona Johnson Iowa Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Robert Sieren mtesdell@yahoo.com Managing Member Kalona Johnson Iowa Scott Freeman Dyan Kriener Signed
505 2021-05-10 07:06 Anonymous (not verified) 69.63.16.2 Three Boys Contracting LLC Limited Liability Company 1108 Cullen Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-08 Brandon J Campbell threeboyscarpentry@gmail.com Tiffin Johnson Iowa Steve Fishman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Brandon J Campbell threeboyscarpentry@gmail.com Managing Member Tiffin Johnson Iowa Steve Fishman Dyan Kriener Signed
856 2022-01-26 13:44 Anonymous (not verified) 69.63.16.2 Rick Peterson Proprietorship 3366 Lynden Heights Rd NE, Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-26 Richard Peterson insurancecommercialsam@greenstate.org Iowa City Johnson Iowa Jonathan Gonzalez Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Rick Peterson insurancecommercialsam@greenstate.org Owner Iowa City Johnson IA Jonathan Gonzalez Dyan Kriener Signed
860 2022-01-27 11:31 Anonymous (not verified) 69.63.16.2 Dreams 2 Reality Construction LLC Limited Liability Company 17615 Meredith Dr, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-26 Rob Rubsam rob@dreams2reality.us Waukee Dallas Iowa Kyle Stahle Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Rob Rubsam rob@dreams2reality.us Member Waukee Dallas Iowa Kyle Stahle Dyan Kriener Signed
861 2022-01-27 11:33 Anonymous (not verified) 69.63.16.2 Dreams 2 Reality Construction LLC Limited Liability Company 17615 Meredith Dr, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-26 Lisa Rubsam lisa@dreams2reality.us Waukee Dallas Iowa Kyle Stahle Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Lisa Rubsam lisa@dreams2reality.us Member Waukee Dallas Iowa Kyle Stahle Dyan Kriener Signed
1153 2022-06-13 16:22 Anonymous (not verified) 216.9.166.5 Ronald B Blakley Proprietorship 2001 St Bridgets Rd NE, Solon IA 52333 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-08 Ronald B Blakley sanjahunt@gmail.com Solon Johnson Iowa Scott G Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Ronald B Blakley Sanjahunt@gmail.com Owner Solon Johnson Iowa Scott G Freeman Dyan Kriener Signed
1544 2023-03-29 16:52 Anonymous (not verified) 94.188.207.228 Live Wire Trucking Limited Liability Company 109 E Marion 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. 2023-03-29 Joshua Allen Moore livewiretruckingIA@gmail.com Sigourney Iowa United States Ethan Weber Dylan Miller Signed (1) The employer does not elect the employers’ liability coverage. Joshua Allen Moore livewiretruckingIA@gmail.com Owner Sigourney Iowa United States Ethan David Weber Dylan Jefferey Miller Signed
819 2022-01-02 11:39 Anonymous (not verified) 184.94.130.66 derek verhelst trucking inc Proprietorship 1579 270th avenue canby mn 56220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-02 derek verhelst derekvtinc@gmail.com canby yellow medicine mn lois verhelst dylan nelson Signed (1) The employer does not elect the employers’ liability coverage. derek verhelst derekvtinc@gmail.com owner canby yellow medicine mn lois verhelst dylan nelson Signed
57 2020-02-10 15:33 Anonymous (not verified) 198.167.182.164 AllEnhancements LLC Limited Liability Company 1122 Woodland Ln, LeClaire, IA 52753 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-31 Brett Allen allenhancementsllc@outlook.com LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Brett Allen allenhancementsllc@outlook.com Managing Member LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed
59 2020-02-11 11:34 Anonymous (not verified) 198.167.182.164 Besch Electric LLC Limited Liability Company 317 Sycamore St, Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-03 Daniel Besch beschd@hotmail.com Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Daniel Besch beschd@hotmail.com Managing Member Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed
60 2020-02-12 10:10 Anonymous (not verified) 198.167.182.164 Sara Torres Proprietorship 419 Lilac St, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-11 Sara Torres skb_blue08@hotmail.com Tiffin Johnson Iowa Steven J Fishman E. Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Sara Torres skb_blue08@hotmail.com Owner Tiffin Johnson Iowa Steven J Fishman E Dyan Kriener Signed
1150 2022-06-10 16:14 Anonymous (not verified) 173.29.125.38 Vernon Tim McClain Limited Liability Company 2717 Thompson ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-10 Vernon Tim McClain mcclainlawn@gmail.com Des Moines POlk Iowa Ilisha Carter Earl Warren Jr. Signed (1) The employer does not elect the employers’ liability coverage. vernon mcclain mcclainlawn@gmail.com business owner des moines polk iowa Ilisha Carter Earl Warren Jr. Signed
1459 2023-02-16 09:07 Anonymous (not verified) 94.188.205.166 Lakerats Limited Liability Company 112 W Court Winterset IA 50273 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-05 Kyra Moore kyra@novushomemortgage.com Urbandale Polk Iowa Jessica Anderson Easton Anderson Signed (1) The employer does not elect the employers’ liability coverage. Kyra Moore kyra@novushomemortgage.com Owner Urbandale Polk Iowa Jessica Anderson Easton Anderson Signed
1548 2023-03-30 14:18 Anonymous (not verified) 94.188.207.229 Lance Jordison Proprietorship 2295 Nelson Ave, Fort Dodge, IA 50501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-30 Lance Jordison jordisontrucking@gmail.com Fort Dodge Webster Iowa Ashlee Neumann Ed Smith Signed (1) The employer does not elect the employers’ liability coverage. Lance Jordison jordisontrucking@gmail.com Owner Fort Dodge Webster Iowa Ashlee Neumann Ed Smith 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
334 2020-12-07 12:38 Anonymous (not verified) 173.19.190.160 Broadband Installations of Iowa LLC Limited Liability Company P.O. Box 728 Carroll, IA 51401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-07 Charles Wood cwood.bband@outlook.com CEDAR RAPIDS IA IA Eva Wood Tamara Wood Signed (1) The employer does not elect the employers’ liability coverage. Skyla Siech skylabbi@outlook.com Offcie Manager Ely Linn Iowa Melvin Harter Eddie Bell Signed
673 2021-10-14 07:15 Anonymous (not verified) 97.125.239.203 Complete tile llc Limited Liability Company 875 se gateway drive #311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-14 Nedzad mustafic completetile1@gmail.com Grimes Usa Iowa Enesa Mustafic Edina avdic Signed (1) The employer does not elect the employers’ liability coverage. Nedzad Mustafic completetile1@gmail.com Owner Grimes Usa Iowa Enesa mustafic Edina avdic Signed
1769 2023-07-31 11:23 Anonymous (not verified) 94.188.207.228 PSI LLC Limited Liability Company 2765 N Center Point Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-31 Esteici Reyes stacy0979@gmail.com Cedar Rapids Linn IA Jeffrey Ventura Eduardo Contreras Signed (1) The employer does not elect the employers’ liability coverage. Esteici Reyes stacy0979@gmail.com Owner Cedar Rapids Linn IA Jeffrey Ventura Eduardo Contreras Signed
778 2021-12-05 11:39 Anonymous (not verified) 71.34.165.66 Perfection heating and Plumbing LLC Limited Liability Company 2522 3 Ave SW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-05 Edward William cooper ecooper@amermech.com Altoona Polk IA Lindsay cooper Edward cooper SR Signed (1) The employer does not elect the employers’ liability coverage. Eddie Cooper ecooper@amermech.com Self Altoona Polk IA Lindsay cooper Edward cooper SR Signed
1994 2024-01-23 14:35 Anonymous (not verified) 94.188.207.229 Josh Oswald Proprietorship 505 Eisenhower Rd., Osceola, IA 50213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-23 Josh Oswald jjoswald47@gmail.com Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed (1) The employer does not elect the employers’ liability coverage. JOSHUA OSWALD jjoswald47@gmail.com Sole Proprietor Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed
1995 2024-01-23 15:08 Anonymous (not verified) 94.188.205.167 Spencer Abbott Proprietorship 1358 170th Ave, Murray Iowa 50174 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-23 Spencer Abbott sabbott1800@gmail.com Murray Clarke Iowa Juanita Yutzy Elaine Lee Signed (1) The employer does not elect the employers’ liability coverage. Spencer Abbott sabbott1800@gmail.com sole proprietor Murray Clarke Iowa Juanita Yutzy Elaine Lee Signed
1708 2023-06-25 15:10 Anonymous (not verified) 94.188.207.228 Lopez concrete Limited Liability Company 2009 otley 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. 2023-06-25 Erick Lopez lopez1concrete@gmail.com Perry Dallas IA Ever tobar. Elba alejandro Signed (1) The employer does not elect the employers’ liability coverage. Erick lopez lopez1concreto@gmail.com Owner Perry Dallas IA Ever tobar Elba alejandro Signed
858 2022-01-27 08:06 Anonymous (not verified) 75.162.81.119 MR Custom Tile & Flooring LLC Limited Liability Company 14390 Newbold 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. 2022-01-27 Matthew Royer royer20@yahoo.com Indianola Warren United States Leiloni Royer Elena Royer Signed (1) The employer does not elect the employers’ liability coverage. Matthew Royer royer20@yahoo.com Myself Indianola Warren United States Leiloni Royer Elena Royer Signed
1084 2022-05-02 15:23 Anonymous (not verified) 173.23.196.11 Sweet Green Arborist Services, LLC Limited Liability Company 804 W. Briggs Ave, Fairfield, IA 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-02 Andrew Forest Nash sweetgreenarborist@gmail.com Fairfield Jeffereson Iowa Eli Morgan Rachel Morgan Signed (1) The employer does not elect the employers’ liability coverage. Andrew Nash anash66@gmail.com same Fairfield Jeffereson Iowa Rachel Morgan Eli Morgan Signed
1067 2022-04-23 11:17 Anonymous (not verified) 166.181.82.231 Black Squirrel Siding LLC. Limited Liability Partnership 1512 north 1st ave 203s I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-23 Robby Bartosh zodzoey19@gmail.com Cedar Rapids IA United States Phoenix Bartosh Elijah Irish Signed (1) The employer does not elect the employers’ liability coverage. Jeremiah Petsche Blacksquirrelsiding@gmail.com business partner coralville johnson iowa Phoenix Bartosh Elijah Irish Signed
958 2022-03-08 20:17 Anonymous (not verified) 50.82.39.158 Ramos Drywall Limited Liability Company 1355 Ozark Ridge, Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-03-08 Carlos Rene Ramos Martinez carlosramos2345@gmail.com Coralville Iowa United States Breanna Barragan Eliseo Tapia JR. Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Carlos Rene Ramos Martinez carlosramos2345@gmail.com N/A- Same Person Coralville Johnson County IA Breanna Barragan Eliseo Tapia JR. Signed
260 2020-09-17 10:52 Anonymous (not verified) 50.80.218.18 Decanus Property Management Proprietorship 102 E 2nd St, Davenport IA 52801 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-17 Shonna Suzanne Dean decanus@yahoo.com Moline Rock Island Illinois Justin E Proctor Elizabeth A Oney Signed (1) The employer does not elect the employers’ liability coverage. Shonna S Dean decanus@yahoo.com Self Moline Rock Island Illinois Justin E Proctor Elizabeth A Oney Signed
1556 2023-04-05 14:08 Anonymous (not verified) 94.188.205.169 Capstone Staffing Solutions LLC Limited Liability Company 315 E 5th St, STE 202, Waterloo, IA, 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-05 Peterson Munyasia pete@capstonestaffingsolutions.com Allen USA TX Daniel Mwangi Elizabeth Munene Signed (1) The employer does not elect the employers’ liability coverage. Peterson Munyasia pete@capstonestaffingsolutions.com Owner Allen USA TX Daniel Mwangi Elizabeth Munene Signed
508 2021-05-10 11:56 Anonymous (not verified) 172.58.83.106 Aldo Monroy Limited Liability Company 201 Ne 44th St , Apt 111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Aldo Monroy Aldogmonroy@gmail.com Ankeny Polk IOWA Aldo Monroy Elizabeth lopez Signed (1) The employer does not elect the employers’ liability coverage. Aldo Monroy Aldogmonroy@gmail.com Owner Ankeny Polk IOWA Aldo g monroy reyes Elizabeth tavarez lopez Signed
1826 2023-08-30 16:38 Anonymous (not verified) 94.188.207.227 IOWA MOLD REMOVAL Limited Liability Company 103 15TH ST SW, ALTOONA, IA 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-30 RHETT OSELETTE RHETT.OSELETTE@GMAIL.COM CLIVE DALLAS IOWA ELLA OSELETTE MYA OSELETTE Signed (1) The employer does not elect the employers’ liability coverage. KATIE BROWN KATIE@IOWAMOLDREMOVAL.COM EMPLOYER ALTOONA POLK IOWA MYA OSELETTE ELLA OSELETTE Signed
269 2020-09-23 09:18 Anonymous (not verified) 76.76.239.60 belilove company of Iowa Inc Limited Liability Company 601 south 23rd street Fairfield Iowa 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-20 James Belilove jimb@cec-waterjet.com Fairfield Jefferson Iowa James thompson ellen bowen Signed (1) The employer does not elect the employers’ liability coverage. James Belilove jimb@cec-waterjet.com Owner and president Fairfield Jefferson Iowa James Thompson Ellen Bowen Signed
1700 2023-06-22 14:53 Anonymous (not verified) 94.188.205.166 James Trotter Limited Liability Company 1341 Cachelin Dr Carter Lake IA 51510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-22 James Trotter trotterwizard@gmail.com Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed (1) The employer does not elect the employers’ liability coverage. James Trotter trotterwizard@gmail.com Self Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed
1701 2023-06-22 15:03 Anonymous (not verified) 94.188.207.228 Midwest Teleworks Limited Liability Company 1341 Cachelin Dr Carter Lake IA 51510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-22 James Trotter trotterwizard@gmail.com Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed (1) The employer does not elect the employers’ liability coverage. James Trotter trotterwizard@gmail.com Owner Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed
2165 2024-04-19 14:05 Anonymous (not verified) 94.188.207.225 Apex Striping LLC Limited Liability Company 1325 Western Ave, cedar Falls, IA. 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-19 Chaz Ernest Torres admin@apexstripingia.com Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed (1) The employer does not elect the employers’ liability coverage. Chaz Ernest Torres admin@apexstripingia.com Self Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed
1101 2022-05-13 12:55 Anonymous (not verified) 174.199.102.54 Daniel Blanco Proprietorship 1403 2nd Ave S I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-13 Daniel Blanco chindan77@yahoo.com Ft Dodge Webster IA Vanessa Blanco Elva Castañeda Signed (1) The employer does not elect the employers’ liability coverage. Daniel Blanco chindan77@yahoo.com Self Ft Dodge Webster IA Vanessa Blanco Elva Castañeda Signed
1989 2024-01-16 17:13 Anonymous (not verified) 94.188.205.168 Xcel Electric LLC Limited Liability Company 1142 Columbus Dr Waterloo Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-16 Haris Mumic h.mumic@hotmail.com Waterloo Black Hawk IA Minea Skrgic-Mumic Elvis Mumic Signed (1) The employer does not elect the employers’ liability coverage. Haris Mumic h.mumic@hotmail.com Owner/Employer waterloo Black Hawk IA Minea Skrgic-Mumic Elvis Mumic Signed
232 2020-08-16 11:28 Anonymous (not verified) 173.27.57.39 Landeros & Sons Construction, Inc Limited Liability Partnership 1636 19th 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. 2020-08-16 Fernando Landeros fland1983@gmail.com Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed (1) The employer does not elect the employers’ liability coverage. Emanuel Landeros fland1983@gmail.com Brother Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed
1315 2022-09-20 13:11 Anonymous (not verified) 173.17.128.203 Leaffilter Proprietorship 1595 Georgetown Rd., Hudson, OH 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-20 Johnny Coker johnnycoker36@gmail.com Altoona Polk Iowa Travis Klapproth Emilie Klapproth Signed (1) The employer does not elect the employers’ liability coverage. LeafFilter support@leafhome.com Sub contractor Grimes Polk Iowa Travis Klapproth Emilie Klapproth Signed
938 2022-02-25 15:21 Anonymous (not verified) 174.215.247.215 Maria castillo Limited Liability Company 2200 scott blvd #90 iowa city iowa 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-25 Maria evangelina castillo moreno mariacastillo852@yahoo.com Iowa city Jonhson Iowa Maria castillo Emilio Castillo Signed (1) The employer does not elect the employers’ liability coverage. Maria evangelina castillo moreno mariacastillo852@yahoo.vom Work Iowa city Johnson Iowa Maria castillo Emilio Castillo Signed
1293 2022-09-03 08:03 Anonymous (not verified) 50.82.244.98 MTZ Drywall Proprietorship 1101 Eighth St, West Des Moines, 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. 2022-09-02 Richar Martinez menace_42@icloud.com West Des Moines United States Iowa Alejandro Gonzalez Emilio Martinez Signed (1) The employer does not elect the employers’ liability coverage. Jerry Jenkins jjenkins@farmersagent.com N/A Urbandale United States Iowa Alejandro Gonzalez Emilio Martinez Signed
143 2020-04-29 09:59 Anonymous (not verified) 173.29.234.11 Plum Communications, LLC Limited Liability Company 1018 NW Campus Ridge 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. 2020-04-29 Brian Shearer brian@plumllc.com Ankeny Polk Iowa Kathryn Shearer Emily Davis Signed (1) The employer does not elect the employers’ liability coverage. Brian Dean Shearer brian@plumllc.com Self Ankeny Polk Iowa Kathryn Shearer Emily Davis Signed
2030 2024-02-07 10:10 Anonymous (not verified) 94.188.207.227 Jason Jacobs Proprietorship 115 West 7th St., Suite 1W, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jason Jacobs jason.jacobs@thrivent.com Spencer Clay Iowa Brad Bernardy Emily Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Jason Jacobs jason.jacobs@thrivent.com Self Spencer Clay Iowa Brad Bernardy Emily Jacobs Signed
1754 2023-07-19 08:52 Anonymous (not verified) 94.188.207.224 Dustin Scoggins Limited Liability Company 1723 19th ave rock island Illinois I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-19 Dustin Shane Scoggins dscoggins625@gmail.com Rock island Rock island county Illinois Emily Smith-Scoggins Emily Smith-Scoggins Signed (1) The employer does not elect the employers’ liability coverage. Dustin Shane Scoggins dscoggins625@gmail.com Self Rock island Rock island county Illinois Emily Smith-Scoggins Emily Smith-Scoggins Signed
1792 2023-08-08 20:19 Anonymous (not verified) 94.188.207.229 Faith Based Construction Limited Liability Company 6820 Holcomb Ave. Apt. 8 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-08 Toby Andrew Johns tobyjohns28@gmail.com URBANDALE Polk United States Melanie Jo Ayersman Emma Stover Signed (1) The employer does not elect the employers’ liability coverage. Toby Andrew Johns tobyjohns28@gmail.com self URBANDALE Polk United States Melanie Jo Ayersman Emma Stover Signed
1935 2023-12-02 18:34 Anonymous (not verified) 94.188.207.229 Wasabi Johnston LLC Limited Liability Company 8184 Birchwood Ct, Johnston IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-02 Jay Wang jaywang@wasabidsm.com Clive Dallas IA Engjin zheng yingna Zheng Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang jaywang@wasabidsm.com self Clive Dallas IA Wenhui Cheng Enjing Zheng Signed
289 2020-10-23 14:42 Anonymous (not verified) 65.103.82.36 Go Green Lawn and Tree Proprietorship 2911 N Harrison st Davenport IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-23 Brandon gogreenlawnandtree@yahoo.com davenport scott iowa Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. brandon gordon gogreenlawnandtree@yahoo.com self davenport scott ia kayla eric Signed
1431 2023-01-25 16:24 Anonymous (not verified) 172.56.249.51 Warren transport Limited Liability Company 3124 titan trail Waterloo,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. 2023-01-25 Lamarcaus Lunford universalvoyager1@gmail.com Elkhart IN Indiana Quinetta shead Eric fikes Signed (1) The employer does not elect the employers’ liability coverage. Lamarcaus Lunford universalvoyager1@gmail.com Owner Elkhart IN Indiana Quinetta shead Eric fikes Signed
2040 2024-02-08 10:35 Anonymous (not verified) 94.188.207.226 Storm Pro Solution Limited Liability Company 1309 Coffeen Sheridan,wy 82801 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-08 Candis Henderson Cneal@stormprosolution.com Broadview Chicago Illinois Chester Neal Eric Henderson Signed (1) The employer does not elect the employers’ liability coverage. Candis Henderson Cneal@stormprosolution.com Self Broadview Chicago Illinois Chester neal Eric Henderson Signed
1649 2023-05-16 11:37 Anonymous (not verified) 94.188.205.175 DEL-TA RESOURCE STAFFING, LLC Limited Liability Company 17735 pinyon lane, Dallas TX 75252 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-16 Solomon Solomon solomon@del-taresourcestaffing.com Dallas Dallas TX John Effang Eric Ijie Signed (1) The employer does not elect the employers’ liability coverage. Registered Agents Inc 315 E 5th St, STE 202 agent@washingtonregisteredagent.com Owner Waterloo Waterloo IA John Effang Eric Ijie Signed
252 2020-09-09 10:38 Anonymous (not verified) 65.103.82.36 KNS Proprietorship PO Box 2632 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-04 Keith N Slyter KNSCONST@gmail.com Davenport Scott Iowa Eric Johnson Dawn Tague Signed (1) The employer does not elect the employers’ liability coverage. Keith N Slyter knsconst@gmail.com self Davenport Scott Ia Dawn Tague Eric Johnson Signed
276 2020-10-08 12:55 Anonymous (not verified) 65.103.82.36 Ron Ray Limited Liability Company 311 N Division Creston Iowa 50801 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-08 Ron L Ray 641-782-0521@gmail.com Creston Union Iowa Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Ron L Ray 641-782-0521@gmail.com Self Creston Union Iowa Kayla Artioli Eric Johnson Signed
320 2020-11-17 10:08 Anonymous (not verified) 65.103.82.36 Brian Behnkendorf dba Dutchmen Services Proprietorship 55 Rose Court West, Geneseo IL 61254 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Brian Behnkendorf 4gbbehnk@gmail.com Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Brian Behnkendorf 4gbbehnk@gmail.com Self Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed
424 2021-03-05 15:56 Anonymous (not verified) 65.103.82.36 Guardian Angel Specialty Cleaners Proprietorship 1018 W 14th Street, 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. 2020-06-18 Leesa Monson LMonson@gmail.com Davenport Scott Iowa Dawn Tague Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Leesa Monson LMonson@gmail.com Self Davenport Scott Iowa Dawn Tague Eric Johnson Signed
425 2021-03-05 16:03 Anonymous (not verified) 65.103.82.36 Ryan Richard Proprietorship 1425 W 34th Street, Davenport IA 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-15 Ryan Richard RRichard@gmail.com Davenport Scott Iowa Dawn Tague Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Ryan Richard RRichard@gmail.com Self Davenport Scott Iowa Dawn Tague Eric Johnson Signed
1046 2022-04-14 08:11 Anonymous (not verified) 104.36.120.68 jet drywall Limited Liability Company 5611 westminster DR #5 cedarfalls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 murion jones jetdrywall.construction@gmail.com cedarfalls black hawk iowa murion parely jones murion jones Signed (1) The employer does not elect the employers’ liability coverage. murion jones jetdrywal.construction@gmail.com owner cedarfalls black hawk iowa Murion Jones JR Eric Jones Signed
1047 2022-04-14 08:11 Anonymous (not verified) 104.36.120.68 jet drywall Limited Liability Company 5611 westminster DR #5 cedarfalls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 murion jones jetdrywall.construction@gmail.com cedarfalls black hawk iowa murion parely jones murion jones Signed (1) The employer does not elect the employers’ liability coverage. murion jones jetdrywal.construction@gmail.com owner cedarfalls black hawk iowa Murion Jones JR Eric Jones Signed
267 2020-09-22 07:04 Anonymous (not verified) 74.84.65.174 Angel Jesus Argueta Proprietorship 1523 Arlington Ave Des Moines, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-22 Angel Jesus Argueta Juanargueta22@yahoo.com Des Moines Polk Iowa Larry Eugene Guire Eric Michael West Signed (1) The employer does not elect the employers’ liability coverage. Angel Jesus Argueta Juanargueta22@yahoo.com Same Des Moines Polk Iowa Larry Eugene Guire Eric Michael West Signed
2137 2024-04-05 10:28 Anonymous (not verified) 94.188.207.227 Innovationsgenc@gmail.com Limited Liability Company 1134 20th 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. 2024-04-05 Juan carlos Soto Deanda charlye2512penelope@gmail.com East Moline IL United States Deja Rivers Eric Schwab Signed (1) The employer does not elect the employers’ liability coverage. Juan carlos Soto Deanda charlye2512penelope@gmail.com Owner East Moline IL United States Deja Rivers Eric Schwab Signed
460 2021-04-05 15:24 Anonymous (not verified) 173.20.169.155 Tim Stiles Proprietorship 726 Grant St PO box 217 Dexter Iowa 50070 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-04 Tim Stiles timcolleenstiles@gmail.com Dexter Dallas Iowa Karen Penton ERIC TIERNAN Signed (1) The employer does not elect the employers’ liability coverage. Tim Stiles timcolleenstiles@gmail.com Same Tim Stiles Dexter Dallas Iowa Karen Penton Eric Tiernan Signed
831 2022-01-12 15:10 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-12 Kyle Alan Schultz schultzkyle01@gmail.com Cedar Falls Black Hawk County Iowa Kari Houle Erica Schultz Signed (1) The employer does not elect the employers’ liability coverage. Cory Allen Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Erica Schultz Signed
477 2021-04-14 11:04 Anonymous (not verified) 65.103.82.36 Lisa Kuhn Proprietorship 427 s Concord Davenport IA 52802 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-09 Lisa Kuhn none@hotmail.com davenport Scott IA Sarah Erick Signed (1) The employer does not elect the employers’ liability coverage. Lisa Kuhn none@hotmail.com self davenport scott IA sarah erick Signed
1021 2022-03-30 11:20 Anonymous (not verified) 173.18.22.217 Arti Concrete Limited Liability Company 6901 SE 14th St Lot #226 Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-30 Gerson David Artero arti.concrete31@gmail.com Des Moines Polk IA Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Gerson David Artero arti.concrete31@gmail.com Owner Des Moines Polk IA Lesa Reeves Erick Schuldt Signed
1205 2022-07-14 13:29 Anonymous (not verified) 173.18.22.217 Residence Electric LLC Limited Liability Company 5465 Mills Civic Pkwy #317 West Des Moines 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-14 Anthony Rivera residenceelectric@outlook.com West Des Moines Polk Iowa Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Anthony Rivera residenceelectric@outlook.com Owner West Des Moines Polk Iowa Lesa Reeves Erick Schuldt Signed
1359 2022-11-04 10:48 Anonymous (not verified) 173.18.22.217 Lewis Enterprises Limited Liability Company 2723 Witmer Street Des Moines Ia 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-04 Corey Lewis coreyboy1990@gmail.com Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Corey Lewis coreyboy1990@gmail.com Owner Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed
1490 2023-03-03 10:31 Anonymous (not verified) 94.188.205.175 Bagby Lawncar and More Limited Liability Company 921 Pleasant Street, Des Moines IA 50309 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-03 Cory Michael Bagby bagbylawncareandmore@gmail.com 921 Pleasant Street Polk Iowa Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Cory Bagby babylawncareandmore@gmail.com Owner Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed
1823 2023-08-29 12:46 Anonymous (not verified) 94.188.205.177 A&S Construction LLC Proprietorship 5920 Village Circle Johnston IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-28 Admir Omerovic sabinamur22@icloud.com 5920 Village Circle Polk IA Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Admir Omerovic sabinamu22@icloud.com Owner Johnston Polk IA Kelly Coluzzi Erick Schuldt Signed
1193 2022-07-08 10:18 Anonymous (not verified) 173.18.22.217 OWWT Limited Liability Company 1915 SE Clovere Ridge Dr. 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. 2022-07-08 Robert M Jackson dgfl08051982@gmail.com Ankeny Polk IA Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Robert M Jackson dgfl08051982@gmail.com Owner Ankeny Polk Iowa Lesa Reeves Erick Sculdt Signed
1190 2022-07-07 12:00 Anonymous (not verified) 172.243.111.71 Breuer Earthworks Inc. Proprietorship 4512 148th Ave Burlington, IA 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 William Breuer breuerearthworks@gmail.com Burlington Des Moines Iowa Donald Breuer Ericka Breuer Signed (1) The employer does not elect the employers’ liability coverage. William Breuer breuerearthworks@gmail.com Owner of Breuer Earthworks Inc. BURLINGTON Iowa United States Donald Breuer Ericka Breuer Signed
835 2022-01-12 17:41 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-13 Brian Christopher Armbruster crossespalms42@gmail.com Waterloo Black Hawk County Iowa Kari Houle Erik Bjorn Nelson Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Erik Bjorn Nelson Signed
1528 2023-03-22 10:37 Anonymous (not verified) 94.188.205.175 Uhl Cattle Company Partnership 3329 Ozark Ave, Mapleton IA 51034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-01 Tonya Jean Uhl tonyajuhl@gmail.com Mapleton Woodbury iowa Keaten Anthony Miller Erik Michael Boyle Signed (1) The employer does not elect the employers’ liability coverage. Tonya Jean Uhl tonyajuhl@gmail.com Owner Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed
1529 2023-03-22 10:40 Anonymous (not verified) 94.188.205.175 Uhl Cattle Company Partnership 3329 Ozark Ave, Mapleton IA 51034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-01 Troy Michael Uhl troyuhl1224@gmail.com Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed (1) The employer does not elect the employers’ liability coverage. Tonya Jean Uhl tonyajuhl@gmail.com Brother Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed
99 2020-03-23 16:47 Anonymous (not verified) 216.96.116.78 B’s Sweet Treats Proprietorship 21484 196th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-23 Brandi Wehr brndwehr54@hotmail.com Sigourney Keokuk IA Erik Wehr Brenda Workman Signed (1) The employer does not elect the employers’ liability coverage. Brandi Wehr brndwrhr54@hotmail.com Self Sigourney Keokuk IA Brenda Workman Erik Wehr Signed
977 2022-03-15 12:04 Anonymous (not verified) 38.108.136.192 Gunner Fogle Proprietorship 307 S. Franklin St. Corydon, IA 50060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Gunner Lee Fogle gunnerfogle@hotmail.com Corydon Wayne IA Jeremy Fogle Erika Fogle Signed (1) The employer does not elect the employers’ liability coverage. Gunner Fogle gunnerfogle@hotmail.com Myself Corydon Wayne IA Jeremy Fogle Erika Fogle Signed
1211 2022-07-18 14:10 Anonymous (not verified) 172.58.85.43 Palomeque Gutter LLC Limited Liability Company 2004 se 24th st Grimes IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-18 Philips Palomeque ecuaphilips94@gmail.com Des Moines IA USA Iowa Philips Peter Palomeque Vallejo Philips Palomeque Signed (1) The employer does not elect the employers’ liability coverage. Philips Palomeque ecuaphilips94@gmail.com Owner Des Moines USA Iowa Philips Peter Palomeque Vallejo Erika Zapata Signed
1474 2023-02-20 19:48 Anonymous (not verified) 94.188.207.230 Individual entity Proprietorship 801 CELTIC DR, Waukee IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Gerardo Castro jackiecastro18@gmail.com Waukee IA United States Jackelin Castro Esmeralda Castro Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Castro jackiecastro18@gmail.com self Waukee Dallas Iowa Jackelin Castro Esmeralda Castro Signed
78 2020-02-25 09:35 Anonymous (not verified) 65.127.131.118 Rey Construction, LLC Proprietorship 3317 Scott Ave Des Moines, iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-02 Juan Raymundo Hernandez reyano43@gmail.com Des Moines polk iowa Rigoberto Mayorga Y Bounv Quang Signed (1) The employer does not elect the employers’ liability coverage. Preferred Interior Construction INC dba PIC INC deb@piciowa.com PIC, INC-contractor, Rey Construction, LLC-subcontractor Altoona IA United States Martin Pinon Evan Bianchi Signed
153 2020-05-12 12:58 Anonymous (not verified) 172.58.86.150 Big Head Burger Limited Liability Company 706 Quincy st. Waterloo, Iowa 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-12 David Westley Bryant questions.bhb@gmail.com Waterloo Black Hawk Iowa Darlean Crawford Everlue Kincaid Signed (1) The employer does not elect the employers’ liability coverage. David Westley Bryant questions.bhb@gmail.com Owner Waterloo Black Hawk Iowa Darlean Crawford Everlue Kincaid Signed
2109 2024-03-21 11:15 Anonymous (not verified) 94.188.205.169 Panameno Stone Proprietorship 3701 SE 18th Ct. Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-21 Domingo Panameno albertpana08@gmail.com Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed (1) The employer does not elect the employers’ liability coverage. Domingo Panameno albertpana08@gmail.com Self Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed
2110 2024-03-21 13:29 Anonymous (not verified) 94.188.205.174 Baroga Stone Masonry LLC Proprietorship 1228 Loomis Ave Des Moines, IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-21 Bacilio Rodriguez barogastonemasonry@gmail.com Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed (1) The employer does not elect the employers’ liability coverage. Bacilio Rodriguez barogastonemasonry@gmail.com Self Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed
2122 2024-03-28 10:15 Anonymous (not verified) 94.188.205.169 Stone Villalobos LLC Limited Liability Company 4231 Morton Ave Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-28 Josue Villalobos villalobosjosue2016@gmail.com Des Moines Polk Iowa Edgar Palomares Fabiola Palomares Recendiz Signed (1) The employer does not elect the employers’ liability coverage. Josue Villalobos villalobosjosue2016@gmail.com Self Des Moines Polk Iowa Edgar Palomares Fabiola Palomares Recendiz Signed
442 2021-03-22 12:14 Anonymous (not verified) 149.20.235.228 Tim Bruck Construction Inc. Proprietorship 348 Highway 44 Rd. Porstmouth, IA 51565 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-22 Timothy Richard Bruck timrbruck@gmail.com Portsmouth Shelby Iowa Heath Ryan Stein Faith Nicole Bruck Signed (1) The employer does not elect the employers’ liability coverage. Tim Richard Bruck timrbruck@gmail.com Self Portsmouth Shelby Iowa Heath Ryan Stein Faith Nicole Bruck 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
682 2021-10-19 16:15 Anonymous (not verified) 65.144.174.26 BBR Tile and Professional Installation LLC Proprietorship 903 School Ave Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-19 Bertin Baltazar baltarey2009@gmail.com Norwalk Warren Iowa Enedelia Bonilla Fernando Garcia Signed (1) The employer does not elect the employers’ liability coverage. Bertin Baltazar baltarey2009@gmail.com Owner Norwalk Warren Iowa Enedelia Bonilla Fernando Garcia Signed
439 2021-03-18 08:09 Anonymous (not verified) 172.58.86.251 Nancy Lopez/Lifetime Roofing and Construction Corpn Proprietorship 2234 Highland St 50315 Des Moines IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-18 Nancy Lopez/ Lifetime Roofing and Construction Corp info@lifetimeroofingdsm.com Des Moines Polk I A Noe Ordaz Fidel Rubio Signed (1) The employer does not elect the employers’ liability coverage. Nancy Lopez info@lifetimeroofingdsm.com Owner Des Moines Polk IA Noe Ordaz Fidel Rubio Signed
667 2021-10-11 19:33 Anonymous (not verified) 104.166.240.24 FS Custom Flooring Limited Liability Company 5729 NW 92nd street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-11 Filip Sakanovic filip@fscustomflooring.com Johnston IA United States Senad Sakanovic Filip Sakanovic Signed (1) The employer does not elect the employers’ liability coverage. FS Tiling and Ceramics filip@fscustomflooring.com N/A Johnston IA United States Senad Sakanovic Filip Sakanovic Signed
2118 2024-03-27 13:25 Anonymous (not verified) 94.188.207.223 Zaragoza Home Solutions LLC Limited Liability Company 1644 E Walnut St. Des Moines IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-27 Roberto C. Curiel zaragozahomesolutionsllc@gmail.com Des Moines Polk Iowa Fabiola Palomares Recendiz Francisco A Palomares Zepeda Signed (1) The employer does not elect the employers’ liability coverage. Roberto C Curiel zaragozahomesolutionsllc@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Recendiz Francisco A Palomares Zepeda Signed
210 2020-07-20 13:28 Anonymous (not verified) 75.162.95.97 RM construction Proprietorship 65 SE 5TH STREET APT 4 DES MOINES IA . 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Rafael Marquez marquezrafael1@outlook.com Des Moines Polk IOWA IOWA Richard Yanez Francisco Garcia Signed (1) The employer does not elect the employers’ liability coverage. Rafael Marquez marquezrafael1@outlook.com owner Des Moines Polk IOWA Richard Yanez Francisco Garcia Signed
1926 2023-11-29 10:45 Anonymous (not verified) 94.188.207.224 M&M Janitorial LLC Limited Liability Company 243 28th St Dr SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Mackenzie Willits mackenziewillits@gmail.com Cedar Rapids Linn United States Fransisco ruiz Alexander ruiz Signed (1) The employer does not elect the employers’ liability coverage. Meyling willits mackenziewillits@gmail.com Owner cedar rapids Linn United States Alexander ruiz Francisco ruiz Signed
1145 2022-06-07 11:14 Anonymous (not verified) 173.30.72.62 Swifty Enterprises Limited Liability Company 1134 Capri Drive 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. 2022-06-07 Daniel Tabaka dmtabaka1@gmail.com Cedar Rapids Linn IA Wilma Janacek Fredrick Janacek Signed (1) The employer does not elect the employers’ liability coverage. Daniel Tabaka dmtabaka1@gmail.copm Self Cedar Rapids Linn IA Wilma Janacek Fredrick Janacek Signed
2009 2024-01-29 22:59 Anonymous (not verified) 94.188.207.226 Kimberly Ruby Reyes Victoriano Proprietorship 1910 Eric 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. 2024-01-29 Kimberly Ruby Reyes Victoriano InOnePieceDrywall@gmail.com Waterloo Black Hawk Iowa Juan Jose Victoriano Ramirez Denir Billy Flores Signed (1) The employer does not elect the employers’ liability coverage. Kimberly Ruby Reyes Victoriano InOnePieceDrywall@gmail.com Owner Waterloo Black Hawk Iowa Juan Jose Victoriano Ramirez Fredy Perez Perez Signed
1198 2022-07-11 15:46 Anonymous (not verified) 74.84.91.178 Dave's Remodeling LLC Limited Liability Company 2308 Long Grove Ct, 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. 2022-06-01 Kim Kern davesremodeling@aol.com Asbury Dubuque Iowa Brenda Lewis Gabe Drewlow Signed (1) The employer does not elect the employers’ liability coverage. Kim Kern davesremodeling@aol.com co-owner Asbury Dubuque Iowa Brenda Lewis Gabe Drewlow Signed
1943 2023-12-06 16:34 Anonymous (not verified) 94.188.207.230 Your Neighbors Pressure Washing LLC Limited Liability Company 2059 Lyon St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Myself Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
1944 2023-12-06 16:41 Anonymous (not verified) 94.188.207.226 Sell Now Iowa Limited Liability Company 5525 Meredith Dr Suite B Des Moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sale Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
1945 2023-12-06 16:47 Anonymous (not verified) 94.188.205.169 Sell Now Iowa Limited Liability Company 5525 Meredith Drive Suite B Des Moines Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sell Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
1946 2023-12-06 16:51 Anonymous (not verified) 94.188.205.168 Blue Sky Renovations Iowa LLC Limited Liability Company 2059 Lyon St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sell Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
313 2020-11-11 20:35 Anonymous (not verified) 174.198.78.148 Wilson Snow Maintenance Proprietorship 3518 183rd Avenue, 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. 2020-11-11 Bruce E. Wilson bewilson83@gmail.com Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Bruce Wilson bewilson83@gmail.com self Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed
1114 2022-05-17 15:30 Anonymous (not verified) 67.212.117.198 Busta Painting Limited Liability Company 610 W 26th st #1 Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 Evan Busta bustapainting@gmail.com Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed (1) The employer does not elect the employers’ liability coverage. Evan Busta bustapainting@gmail.com Self Employeed Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed
1411 2023-01-06 12:35 Anonymous (not verified) 72.255.93.91 Amayas Painting Proprietorship 1501 Mattern Ave, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-01 Carlos Alexando Amaya Garcia bmoellers@thebookkeepersinc.net Des moines Polk IA Tammy Robbins Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Brett Moelles bmoellers@thebookkeepersinc.net Accountant Des Moines Polk IA Tammy Robbins Gary Cort Signed
1412 2023-01-06 12:38 Anonymous (not verified) 72.255.93.91 Espindola Painting Services Proprietorship 4701 Woodland Ave Unit 3, West Des Moines, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Hugo Espindola bmoellers@thebookeepersinc.net Des Moines Polk IA Jenny Espindola Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Brett Moellers bmoellers@thebookkeepersinc.net Accountant Des Moines Polk IA Jenny Espindola Gary Cort Signed
1918 2023-11-21 12:45 Anonymous (not verified) 94.188.205.167 515 PAINTING LLC Limited Liability Company PO Box 157, Berwick, IA 50032 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Marvin Parker gcort06@gmail.com Berwick Polk Iowa Dillon Parker Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Marvin Parker gcort06@gmail.com Owner Berwick Polk Iowa Dillon Parket Gary Cort Signed
1570 2023-04-12 18:09 Anonymous (not verified) 94.188.205.166 Staley Engineering Consultants, LLC Limited Liability Company 4212 Holland Drive, Des Moines, 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. 2023-04-12 Donald K Staley Don.Staley@q.com Des Moines Iowa United States Kendall S. Staley Gary D. Hlavka Signed (1) The employer does not elect the employers’ liability coverage. Donald K Staley Don.Staley@q.com Owner Des Moines Iowa United States Kendall S. Staley Gary D. Hlavka Signed
1725 2023-07-07 13:37 Anonymous (not verified) 94.188.205.167 Liana Fatino Limited Liability Company 1930 se 14th des moines iowa 50321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-07 Liana Fatino lfatino@yahoo.com des moines USA Iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com wife des moines USA iowa Liana Fatino Gary Fatino Signed
1734 2023-07-11 08:25 Anonymous (not verified) 94.188.207.226 LBN LLC Limited Liability Company 1930 se 14th Des Moines Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Liana Fatino lfatino@yahoo.com Des Moines Polk Iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com owner des moines polk Iowa Liana Fatino Gary Fatino Signed
1735 2023-07-11 08:28 Anonymous (not verified) 94.188.207.229 LBN LLC Limited Liability Company 1930 se 14th Des Moines Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Gary Fatino fatinomarketinggroup@yahoo.com Des Moines polk Iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Gary Fatino fatinomarketinggroup@yahoo.com owner des moines polk iowa liana fatino gary fatino Signed
1736 2023-07-11 08:30 Anonymous (not verified) 94.188.207.228 Scornos Waukee LLC Limited Liability Company 286 w hickman rd waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Liana Fatino lfatino@yahoo.com des moines polk iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com owner des moines polk IOWA Liana Fatino Gary Fatino Signed
1737 2023-07-11 08:32 Anonymous (not verified) 94.188.207.223 Scornos waukee llc Limited Liability Company 286 w hickman rd waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Gary Fatino fatinomarketinggroup@yahoo.com des moines polk iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Gary Fatino fatinomarketinggroup@yahoo.com owner des moines polk iowa Liana Fatino Gary Fatino Signed
982 2022-03-17 09:22 Anonymous (not verified) 65.132.173.234 DAVE GARDNER CONSTRUCTION Proprietorship 11936 KIMBALL AVE WATERLOO IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-17 DAVE GARDNER djg201312@gmail.com Waterloo Black Hawk Iowa Amy Picha Gary Rankin Signed (1) The employer does not elect the employers’ liability coverage. Dave Gardner djg201312@gmail.com self Waterloo Black Hawk IA Amy Picha Gary Rankin Signed
429 2021-03-10 12:52 Anonymous (not verified) 173.23.50.65 Raleigh Electrical Services Limited Liability Company 3747 SE 10th St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-10 Timothy Bruce Raleigh tim@raleighelectrical.org Des Moines Polk Iowa Joe Coughlon Genna Prine Signed (1) The employer does not elect the employers’ liability coverage. Timothy Bruce Raleigh tim@raleighelectrical.org Same Des Moines Polk Iowa Joe Coughlon Genna Prine Signed
970 2022-03-14 14:08 Anonymous (not verified) 174.199.79.176 Friends Transportation Services LLC Limited Liability Company 6010 Creston Ave Unit 26, Des Moines, IA 50321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Mohammed Dood mohedali777@hotmail.com Des Moines Polk Iowa Leigh Laven Geoff Matlock Signed (1) The employer does not elect the employers’ liability coverage. Mohammed Dood mohedali777@hotmail.com Owner Des Moines Polk Iowa Leigh Laven Geoff Matlock Signed
2134 2024-04-04 08:10 Anonymous (not verified) 94.188.205.169 TERRA CONSTRUCTION LLC Limited Liability Company 621 Oak Park Ave Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-04 Bryce Shabazz block.radio@yahoo.com Des Moines Polk Iowa Megan Donigan George Hana Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jessica L Heller Jessica.heller@adp.com Insurance Agent Allentown Lehigh PA Megan Donigan George Hana Signed
536 2021-06-07 11:01 Anonymous (not verified) 205.221.255.62 Mark Lile Limited Liability Partnership PO Box 36411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-07 Martin Luverne Humphrey Jr martinhumphreu@gmail.com Des Moines Polk Iowa Jaimi Humphrey George Porter Signed (1) The employer does not elect the employers’ liability coverage. Mark Lile Mark@ultimateautowash.com Employer Des Moines Polk Iowa Jaimi Humphrey George Porter 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
309 2020-11-09 12:17 Anonymous (not verified) 70.184.213.31 Gerald Gerhardt Proprietorship 104 S 3rd Street, Villisca, IA 50864 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-03 Gerald Gerhardt jerrygerhardt1280@gmail.com Villisca Montgomery IA Tony W. Johnson Gerald Gerhardt Signed (1) The employer does not elect the employers’ liability coverage. Smith Davis Insurance tony@smithdavisins.com Client Papillion Sarpy IA Tony W. Johnson Gerald Gerhardt Signed
581 2021-07-22 14:29 Anonymous (not verified) 205.221.255.62 MartinHumphrey Limited Liability Company Cummins Rd. Apt 202 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Martin Luverne Humphrey Jr. martinhumphreu@gmail.com Des Moines Polk Ioea George Porter Gerald Lund Signed (1) The employer does not elect the employers’ liability coverage. Martin Luverne Humphrey Jr martinhumphreu@gmail.com Self Des Moines Polk Iowa George Porter Gerald Lund Signed
822 2022-01-04 16:59 Anonymous (not verified) 173.22.62.131 Gerardo Calvillo Limited Liability Company 1802 mondamin ave,Des Moines,iowa. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-04 Gerardo Calvillo joedhsanchez@icloud.com Des Moines Polk Iowa Aurora Maciel colín Gerardo Calvillo Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Calvillo joedhsanchez@icloud.com Self Des Moines Polk Iowa Aurora maciel colín Gerardo Calvillo Signed
1509 2023-03-09 10:39 Anonymous (not verified) 94.188.207.227 Andres Barboza Limited Liability Company 329 West 31 St South Sioux city ne 68776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Andres Barboza barboza79@yahoo.com South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra Signed (1) The employer does not elect the employers’ liability coverage. Andres Barboza barboza79@yahoo.com Owner South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra 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
1512 2023-03-10 09:44 Anonymous (not verified) 94.188.205.169 eliseo isai Proprietorship 5301 SE 24th St Des Moines, IA 50320 United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-08 eliseo isai carranza perez Misaelballeza40@gmail.com desmoines polk iowa Julio Nolvela giovanni nolvela Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. eliseo isai carranza perez Misaelballeza40@gmail.com self desmoines polk iowa Julio Nolvela giovanni nolvela Signed
1251 2022-08-11 09:11 Anonymous (not verified) 174.255.1.226 Two Crew Remodeling and Maintenance Limited Liability Partnership 11 C Ave Newhall, Iowa, 52315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-11 Trenten John Schafer Twocrewremodeling@gmail.com Newhall Benton Iowa Joeseph Allen Alger Glenn Mitchel Kieler Signed (1) The employer does not elect the employers’ liability coverage. Jordan McArtor Mcartorjordan@gmail.com Part owner cedar rapids CEDAR RAPIDS, IA (Inside) LINN Iowa Joeseph Allen Alger Glenn Mitchel Kieler Signed
1420 2023-01-12 13:42 Anonymous (not verified) 75.162.144.157 Clearer Sky Limited Liability Company 2305 Drake Park 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. 2023-01-12 Osvaldo Mayorga Delgado grae1524@gmail.com Des Moines Polk Iowa Juan Manuel Mayorga Delgado Gloria Lorena Enamorado Guzman Signed (1) The employer does not elect the employers’ liability coverage. Osvaldo Mayorga Delgado Grae1524@gmail.com Self Des Moines Polk Iowa Juan Manuel Mayorga Delgado Gloria Lorena Enamorado Guzman Signed
118 2020-04-13 11:48 Anonymous (not verified) 173.26.152.222 Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc Limited Liability Company 320 Broadway St PO Box 2727 Waterloo IA 50704 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-14 Joseph D. Sobczyk joczyk@aol.com Cedar Falls Black Hawk Iowa George W. Karnick Glynis R. Worthington Signed (1) The employer does not elect the employers’ liability coverage. Joseph D. Sobczyk joczyk@aol.com self Cedar Falls Black Hawk Iowa George W. Karnick Glynis R. Worthington Signed
121 2020-04-14 15:11 Anonymous (not verified) 173.31.176.75 Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc Limited Liability Company 320 Broadway St PO Box 2727 Waterloo IA 50704 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-14 Michele E Collison darmstad48@aol.com Denver Bremer Iowa George W. Karnick Glynis R. Worthington Signed (1) The employer does not elect the employers’ liability coverage. Joseph D. Sobczyk joczyk@aol.com Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. Denver Bremer Iowa George W. Karnick Glynis R. Worthington Signed
292 2020-10-27 18:15 Anonymous (not verified) 173.19.162.248 John Lass Limited Liability Company 6025 SE 16TH 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. 2020-10-27 John Lass johnwlass@gmail.com Des Moines IA United States Dawn Lass Gordon Lamp Jr. Signed (1) The employer does not elect the employers’ liability coverage. John Lass johnwlass@gmail.com self Des Moines IA United States Dawn Lass Gordon Lamp Jr 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
1379 2022-11-22 11:44 Anonymous (not verified) 166.181.89.236 365 Services LLC Limited Liability Company 306 hayes st e hazleton iowa 50641 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-22 Clayton marshall davis Lcrc365@outlook.com Hazleton Bucanan Iowa Grace lilibridge Kurt king Signed (1) The employer does not elect the employers’ liability coverage. Clayton marshall davis Lcrc365@outlook.com Owner Hazleton Bucanan Iowa Kurt kind Grace lilibridge Signed
1020 2022-03-29 16:53 Anonymous (not verified) 207.32.60.144 J.A. Dahlhauser, Ltd. Proprietorship 1741 Hwy. 7 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Jaylin A. Dahlhauser jaydahlhauser@gmail.com Newell IA United States Matthew McClellan Gracelin R. Dahlhauser Signed (1) The employer does not elect the employers’ liability coverage. Jaylin A. DAhlhauser jaydahlhauser@gmail.com Owner Newell IA United States Matthew McClellan Gracelin R. Dahlhauser Signed
125 2020-04-20 19:01 Anonymous (not verified) 67.22.196.182 Driven School of Driving Limited Liability Company 451 E 1st ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-20 Justin J. Franken drivenschoolofdriving@gmail.com Sioux Center Sioux IA Robyn Franken Gracyn Franken Signed (1) The employer does not elect the employers’ liability coverage. Justin Franken drivenschoolofdriving@gmail.com Me Sioux Center Sioux IA Robyn Franken Gracyn Franken Signed
2071 2024-03-01 11:08 Anonymous (not verified) 94.188.207.229 Level92 Screen Printing LLC Limited Liability Company 2500 W 2nd Ave Ste 10, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-01 Alison Vice orders@level92.com Indianola Warren IA Jake Vice Grant Darrah Signed (1) The employer does not elect the employers’ liability coverage. Alison Vice orders@level92.com Partner Indianola Warren IA Jake Vice Grant Darrah Signed
1623 2023-05-02 14:09 Anonymous (not verified) 94.188.207.226 Leafhome Solutions LLC Limited Liability Company 1595 Georgetown Road Hudson, Ohio 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-02 Grant Anders Scott G2designLLC@yahoo.com Des Moines Polk Iowa Katherine Scott Brian Yurko Signed (1) The employer does not elect the employers’ liability coverage. Brian Yurko byurko@leafhome.com Recruiter Hudson Summit Ohio Katherine Scott Grant Scott Signed
669 2021-10-13 08:24 Anonymous (not verified) 64.191.11.62 E360 Building Company, Inc. Proprietorship PO Box 363, Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-13 Mark Miller mark@e360buildingco.com Cedar Falls Black Hawk Iowa Laetyn Miller Grant Williamson Signed (1) The employer does not elect the employers’ liability coverage. Mark Miller markm@cfu.net Self Cedar Falls Black Hawk Iowa Laetyn Miller Grant Williamson Signed
2102 2024-03-18 10:56 Anonymous (not verified) 94.188.207.228 NBJ Construction LLC Limited Liability Company 2536 Capitol Ave Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Byron Jose Hernandez Nunez bjhernandez198807@gmail.com Des Moines Polk Iowa Nathan Miller Greg Beck Signed (1) The employer does not elect the employers’ liability coverage. NBJ Construction LLC bjhernandez198807@gmail.com Owner Des Moines Polk Iowa Nathan Miller Greg Beck Signed
1783 2023-08-04 10:17 Anonymous (not verified) 94.188.207.229 Lundin trucking llc Limited Liability Company 322 w wilson street preston iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-04 Devin dallas lundin devinlundin@hotmail.com Preston Jackson Iowa Kathy kilburg Greg kilburg Signed (1) The employer does not elect the employers’ liability coverage. Devin lundin devinlundin@hotmail.com Owner Preston Jackson Iowa Kathy kilburg Greg kilburg Signed
1642 2023-05-12 07:29 Anonymous (not verified) 94.188.205.169 HARI SWAMI LLC Limited Liability Company 2759 Mt Pleasant St, Burlington, IA 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-12 BRANDON KELLY MARKWILLIAMSPRO@GMAIL.COM FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed (1) The employer does not elect the employers’ liability coverage. BRANDON KRLLY MARKWILLIAMSPRO@GMAIL.COM SELF FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed
866 2022-01-27 19:15 Anonymous (not verified) 199.66.15.25 Greg Cheno Services LLC Limited Liability Company 203 N H 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. 2022-01-27 Gregory Chenoweth gregcheno@gmail.com Indianola IA United States Rebecca Sue Abbott Gregory Blair Abbott Signed (1) The employer does not elect the employers’ liability coverage. Gregory J. Chenoweth gregcheno@gmail.com Same Indianola Warren Iowa Rebecca Sue Abbott Gregory Blair Abbott Signed
314 2020-11-13 10:18 Anonymous (not verified) 66.172.192.197 Helaine W. Sherman Trust Proprietorship P.O. Box 717, Sioux City, Iowa 51102 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed (1) The employer does not elect the employers’ liability coverage. Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Trustee of Trust Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed
1592 2023-04-22 22:46 Anonymous (not verified) 94.188.207.223 D&L painting LLC Limited Liability Company 3109 E13th st des moines IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-22 Lenin Borjas Varela leninborjas92@gmail.com Des moines Iowa Iowa Berenice Silva Gustado Valdes Signed (1) The employer does not elect the employers’ liability coverage. Lenin Borjas Varela leninborjas92@gmail.com Dueño Clive Iowa Iowa Berenice silva Gustado Valdes Signed
183 2020-06-12 08:23 Anonymous (not verified) 107.77.173.7 A&W Marble & Tile Proprietorship 5624 Sw 5Th Pl I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-12 Wayne A Yergy wyergy@gmail.com Des Moines IA United States Michael L Smith Guy B Chaney Signed (1) The employer does not elect the employers’ liability coverage. Wayne Yergy wyergy@gmail.com Self Des Moines IA United States Michael L Smith Guy B Chaney Signed
1487 2023-02-27 22:12 Anonymous (not verified) 94.188.207.224 Panda garden Proprietorship 105 2nd Ave se cresco ia 52136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-10 Jing Chen jingchen9968@gmail.com Cresco Howard Iowa Leyang Zhou Guy Chen Signed (1) The employer does not elect the employers’ liability coverage. Jing Chen jingchen9968@gmail.com Self Cresco Howard Iowa Leyang zhou Guy Chen Signed
844 2022-01-20 08:55 Anonymous (not verified) 172.58.87.106 Barkley Coatings Limited Liability Company 305 E 20th St S I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-20 Heath barkleyheath@yahoo.com Newton United States Iowa Matthew Blunk Hailey Scott Signed (1) The employer does not elect the employers’ liability coverage. Heath Barkley barkleyheath@yahoo.com Owner Newton IA United States Matthew Blunk Hailey Scott Signed
1624 2023-05-03 10:30 Anonymous (not verified) 94.188.207.227 Ryan Deymonaz Proprietorship 2303 Kingsway 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. 2023-05-03 Ryan Deymonaz ryan.deymonaz@gmail.com Bettendorf Iowa United States Ryan Deymonaz Hannah Baker Signed (1) The employer does not elect the employers’ liability coverage. Ryan Deymonaz ryan.deymonaz@gmail.com Self Bettendorf Iowa United States Ryan Deymonaz Hannah Baker Signed
414 2021-02-28 15:32 Anonymous (not verified) 174.198.75.211 Charlie Christian Hutt Proprietorship 609 E. 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. 2021-01-29 Charlie Christian Hutt bmxican_04@hotmail.com Brooklyn poweshiek IA gene shafbough hannah hutt Signed (1) The employer does not elect the employers’ liability coverage. Charlie Christian Hutt bmxican_04@hotmail.com sole Brooklyn poweshiek IA gene shafbough hannah hutt Signed
1819 2023-08-26 00:50 Anonymous (not verified) 94.188.205.177 JnP Enterprise LLC D/B/A/ JnP Trucking Limited Liability Company 110 Elizabeth St W Grand Junction, IA. 50107 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-26 Patrick Cook pat@jnp-enterprise.com Grand Junction Iowa United States Mary J Mack Hayden M Cook Signed (1) The employer does not elect the employers’ liability coverage. Patrick Cook pat@jnp-enterprise.com 50% Member, Owner, Operator Grand Junction Iowa United States Mary J Mack Hayden M Cook Signed
1538 2023-03-27 15:20 Anonymous (not verified) 94.188.205.167 Luke Woods Limited Liability Company 1513 Burnett Station Road 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. 2023-03-27 Luke James Woods woodsmencontractingllc@gmail.com Central City Linn Iowa Keith John Woods Heath John Woods Signed (1) The employer does not elect the employers’ liability coverage. Luke James Woods woodsmencontractingllc@gmail.com same person Central City Linn Iowa Keith John Woods Heath John Woods 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
715 2021-11-05 11:27 Anonymous (not verified) 209.252.172.87 Ken Clifford Proprietorship 132121st Ave SW Cedar Rapids, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-18 Ken Clifford ken40406108@gmail.com Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Ken Clifford ken40406108@gmail.com Self Employer Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
716 2021-11-05 13:22 Anonymous (not verified) 209.252.172.87 Rick Clifford Clifford Custom Tile & Flooring Proprietorship 1563 Palmer Ct NE, Solon, IA 52333 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-24 Rick Clifford cliffordcustomtile@gmail.com Solon Johnson Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Rick Clifford Clifford Custom Tile & Flooring cliffordcustomtile@gmail.com Self Employed Solon Johnson Iowa Sarah Coberley Heather Howell Signed
717 2021-11-05 13:32 Anonymous (not verified) 209.252.172.87 Nick Wiles CW Flooring LLC Limited Liability Company Po Box 445, 710 6th St Wellman, IA 52356 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-24 Nick Wiles CW Flooring LLC nickwiles007@gmail.com Wellman Washington Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Nick Wiles CW Flooring LLC nickwiles007@gmail.com Self Employed Wellman Washington Iowa Sarah Coberley Heather Howell Signed
718 2021-11-05 13:41 Anonymous (not verified) 209.252.172.87 Wayne Hunt Proprietorship 405 E 4th St Tipton, Ia 52772 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-12 Wayne Hunt installation@bachmeiercarpetone.com Tipton Cedar Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Wayne Hunt installation@bachmeiercarpetone.com Self Tipton Cedar Iowa Sarah Coberley Heather Howell Signed
721 2021-11-05 14:04 Anonymous (not verified) 209.252.172.87 Mike Kraus Proprietorship 212 2nd St Buffalo, Ia 52728 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-17 Mike Kraus mjkraus4356@gmail.com Buffalo Scott Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Mike Kraus mjkraus4356@gmail.com Self Employed Buffalo Scott Iowa Sarah Coberley Heather Howell Signed
722 2021-11-05 14:07 Anonymous (not verified) 209.252.172.87 Jeremiah Lunsford Proprietorship 624 Carroll Dr SE, Cedar Rapids, IA 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-10 Jeremiah Lundsford jjaylunsford@gmail.com Cedar Paids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jeremiah Lunsford jjaylunsford@gmail.com Self Employed Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
723 2021-11-05 14:13 Anonymous (not verified) 209.252.172.87 Will Lacina Northstar Hardwood Floors Proprietorship 1211 G St Amana, IA 52203 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-16 Will Lacina northstarhardwoodfloor@gmail.com Amana Iowa Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. William Lacina northstarhardwoodfloor@gmail.com Self Employed Amana Iowa Iowa Sarah Coberley Heather Howell Signed
724 2021-11-05 14:25 Anonymous (not verified) 209.252.172.87 Josh Peterson Proprietorship 121 Karen Drive, Williamsburg, IA 52361 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-15 Josh Peterson tanyataz@msn.com Williamsburg Iowa Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Josh Peterson tanyataz@msn.com Self Employed Williamsburg Iowa Iowa Sarah Coberley Heather Howell Signed
725 2021-11-05 14:32 Anonymous (not verified) 174.198.66.202 Jay Schulte Proprietorship 7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 Jay Schulte schultejay@Hotmail.com Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jay Schulte schultejay@hotmail.com Self Employed Cedar Rapids Linn Ia Sarah Coberley Heather Howell Signed
726 2021-11-05 14:39 Anonymous (not verified) 174.198.66.202 John Stoltzfus JM Tile LLC Limited Liability Company Wellman, Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-19 John Stoltzfus installation@bachmeiercarpetone.com Wellman Washington Iowa Sarah Coberley Heather Howell Signed (1) The employer does not elect the employers’ liability coverage. John Stoltzfus installation@bachmeiercarpetone.com Self Wellman Washington Iowa Sarah Coberley Heather Howell Signed
727 2021-11-05 14:46 Anonymous (not verified) 174.198.66.202 Bret Swift Swift Enterprises Proprietorship 2240 Coldstream Drive 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. 2020-01-13 Brett Swidt swiftenterprises@me.com Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed (1) The employer does not elect the employers’ liability coverage. Bret Swift swiftenterprises@me.com Self Employed Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
728 2021-11-05 14:52 Anonymous (not verified) 209.252.172.87 Stacy Wade Wade Flooring Specialist Proprietorship 2481 247th St, Washington, IA 52353 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 Stacy Wade stacywade92@gmail.com Washington Washington Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Stacy Wade stacywade92@gmail.com Self Washington Washington Iowa Sarah Coberley Heather Howell Signed
729 2021-11-05 15:25 Anonymous (not verified) 209.252.172.87 Joshua Yoder S&S Window Treatments Proprietorship 2555 Hwy 1 SW, Iowa City Iowa 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-20 Joshua Yoder installation@bachmeiercarpetone.com Iowa City Johnson Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Joshua Yoder installation@bachmeiercarpetone.com Owner Iowa City Johnson Iowa Sarah Coberley Heather Howell Signed
1074 2022-04-27 12:16 Anonymous (not verified) 66.129.216.227 Kristyn M Gerst Counseling LLC Limited Liability Company 30 Villager Dr. Apt. 3 North Liberty, IA 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-27 Kristyn May Gerst kmwatson18@gmail.com North Liberty johnson Iowa Forrest John Gerst Heather Lynn Watson Signed (1) The employer does not elect the employers’ liability coverage. Kristyn May Gerst kmwatson18@gmail.com self North Liberty Johnson Iowa Forrest John Gerst Heather Lynn Watson 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
705 2021-11-02 11:41 Anonymous (not verified) 173.23.180.159 Simri Enterprise LLC Limited Liability Company 614 Ricker St Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-02 Noemi Del Carmen Trinidad simdelenterprisellc@gmail.com Waterloo Black Hawk Iowa Karla Axume Helmer Linares Signed (1) The employer does not elect the employers’ liability coverage. Simri Y Aldana simdelenterprisellc@gmail.com Owner Waterloo Black Hawk Iowa Karla Axume Helmer Linares Signed
707 2021-11-03 15:30 Anonymous (not verified) 173.23.180.159 Simdel Enterprise LLC Limited Liability Company 614 Ricker St Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-03 Noemi Del Carmen Trinidad simdelenterprisellc@gmail.com Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed (1) The employer does not elect the employers’ liability coverage. Simri Y Aldana simdelenterprisellc@gmail.com Owner Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed
708 2021-11-03 15:37 Anonymous (not verified) 173.23.180.159 Simdel Enterprise LLC Limited Liability Company 614 Ricker St. Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-03 Simri Yonelda Aldana Leiva simdelenterprisellc@gmail.com Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed (1) The employer does not elect the employers’ liability coverage. Noemi Del Carmen Trinidad simdelenterprisellc@gmail.com Owner Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed
791 2021-12-14 11:35 Anonymous (not verified) 108.178.194.186 Leaf Home solutions LLC Limited Liability Company 1595 Georgetown rd. Hudson OH 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-14 Abelardo Lino Montes alinomontes@gmail.com Le claire IA 52753 Scott Iowa Ann Pelton Herman Roche Signed (1) The employer does not elect the employers’ liability coverage. Abelardo Lino Montes alinomontes@gmail.com Owner Le Claire Scott IA Ann Pelton Herman Roche Signed
771 2021-11-22 20:29 Anonymous (not verified) 75.162.65.250 Art Flooring LLC Limited Liability Company 1225 Emma Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-23 Antonio Rojas artfloorsllc@gmail.com 1225 Emma Ave Polk Iowa Antonio Rojas Hilda Rojas Signed (1) The employer does not elect the employers’ liability coverage. Antonio Rojas artfloorsllc@gmail.com self same as above same as above iowa Antonio Rojas Hilda Rojas Signed
1123 2022-05-22 14:32 Anonymous (not verified) 173.24.108.210 Daly Building Service, LLC Limited Liability Company 409 Dammann Dr. Eldridge IA. 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-22 Noah Taylor Daly Noahdalyubs@Gmail.com Eldridge Scott County Iowa Corinna Daly Holly Roberts Signed (1) The employer does not elect the employers’ liability coverage. Noah Taylor Daly Noahdalyubs@Gmail.com Owner Eldridge Scott County Iowa Corinna Daly Holly Roberts Signed
12 2019-12-17 19:54 Anonymous (not verified) 50.83.188.192 B & B Construction Proprietorship 2463 93rd Avenue 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. 2019-12-17 Brock A Maxwell brock246393@gmail.com Des Moines IA United States Hope Winegardner Yvonne Ginther Signed (1) The employer does not elect the employers’ liability coverage. Brock A Maxwell brock246393@gmail.com Owner Des Moines POlK Iowa Yvonne Ginther Hope Winegardner Signed
1250 2022-08-10 09:10 Anonymous (not verified) 75.162.190.54 Merit Paint Company Proprietorship 1629 24th St, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-10 James Edward Simpson jaybirdsimpson40@aol.com Des Moines Polk Iowa Regan Simpson Hudson Simpson Signed (1) The employer does not elect the employers’ liability coverage. James Simpson jaybirdsimpson40@aol.com Owner Des Moines Polk Iowa Regan Simpson Hudson Simpson 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
674 2021-10-15 09:43 Anonymous (not verified) 173.29.63.3 Peter Hawley Proprietorship 524 n galena ave, Wyoming Illinois 61491 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-15 Peter Anthony Hawley hawleypete801@gmail.com Wyoming Stark Illinois Elizabeth Doreen Hawley Ian Matthew Esmoil Signed (1) The employer does not elect the employers’ liability coverage. Peter Anthony Hawley hawleypete801@gmail.com Self Wyoming Stark IL Elizabeth Doreen Hawley Ian Matthew Esmoil Signed
437 2021-03-16 18:31 Anonymous (not verified) 38.121.121.16 Thompsen Irrigation Proprietorship 16086 Missouri Ave Crescent IA 51526 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-17 James R Thompsen jthom76285@aol.com Crescent Pottawattamie Iowa Mike Harmon Ilene Harmon Signed (1) The employer does not elect the employers’ liability coverage. James R Thompsen jthom76285@aol.com self Crescent Pottawattamie Iowa Mike Harmon Ilene Harmon Signed
1750 2023-07-17 11:00 Anonymous (not verified) 94.188.205.166 Mario Flores Proprietorship 2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Mario Zubia Flores deb@piciowa.com Des Moiines Polk Iowa Inspro employee 2022 Inspro employee 2022 Signed (1) The employer does not elect the employers’ liability coverage. Mario Zubia Flores deb@piciowa.com self Des Moines Polk Iowa Inspro employee 2022 Inspro employee 2022 Signed
1751 2023-07-17 11:00 Anonymous (not verified) 94.188.205.166 Mario Flores Proprietorship 2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Mario Zubia Flores deb@piciowa.com Des Moiines Polk Iowa Inspro employee 2022 Inspro employee 2022 Signed (1) The employer does not elect the employers’ liability coverage. Mario Zubia Flores deb@piciowa.com self Des Moines Polk Iowa Inspro employee 2022 Inspro employee 2022 Signed
1749 2023-07-17 10:52 Anonymous (not verified) 94.188.205.175 Zenon Loreto Proprietorship 1324 E 29th St Des Moines, IOwa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-17 Zenon Loreto deb@piciowa.com Des Moines Polk Iowa Inspro in 2019 Inspro in 2019 Signed (1) The employer does not elect the employers’ liability coverage. Zenon Loreto deb@piciowa.com self Des Moines Polk Iowa Inspro in 2019 Inspro in 2019 Signed
1625 2023-05-04 14:07 Anonymous (not verified) 94.188.207.228 Extreme Repair, LLC Limited Liability Company 300 North Carthage 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. 2023-05-04 Tony Cleveland extremerepair1@yahoo.com EXIRA, IA Audubon United States Katherine Cleveland Isaac Kommes Signed (1) The employer does not elect the employers’ liability coverage. Extreme Repai,r LLC extremerepair1@yahoo.com Self EXIRA, IA Audubon United States Katherine Cleveland Isaac Kommes Signed
1707 2023-06-25 10:39 Anonymous (not verified) 94.188.207.224 Michael D Ray Proprietorship 4944 Holcomb 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. 2023-06-22 Michael D Ray Jr mdray01@msn.com Des Moines Polk Iowa Bonnie R Finken Isaiah O Washington Signed (1) The employer does not elect the employers’ liability coverage. Michael D Ray mdray01@msn.com Owner Proprietor Des Moines Polk Iowa Bonnie R Finken Isaiah O Washington Signed
105 2020-03-27 12:15 Anonymous (not verified) 174.219.134.4 Elijah Willier Proprietorship 805 SE 15th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-27 Elijah Willier e.willier42798@gmail.com Grimes Polk IA Isaac Willier Isaiah Willier Signed (1) The employer does not elect the employers’ liability coverage. Elijah Willier e.willier42798@gmail.com Self/ sole proprietor Grimes Polk IA Isaac Willier Isaiah Willier Signed
385 2021-02-07 12:43 Anonymous (not verified) 173.17.12.148 H@E roofing LLC Limited Liability Company 1912 Burson street Des Moines is 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-04 Heather Hickman hratherhickman@gmail.com Des moines Polk Iowa Jerry freeborn Ivan torres Signed (1) The employer does not elect the employers’ liability coverage. Heather Hickman hratherhickman@gmail.com Self Des moines Polk Iowa Jerry freeborn Ivan torres Signed
1308 2022-09-14 21:25 Anonymous (not verified) 166.196.110.63 Anhalt Trucking Limited Liability Company Canby MN I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-13 Jordan J Anhalt anhalt.trucking@gmail.com Canby MN United States Ashley Anhalt Jace Anhalt Signed (1) The employer does not elect the employers’ liability coverage. Jordan J Anhalt anhalt.trucking@gmail.com Same Canby MN United States Ashley Anhalt Jace Anhalt 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
212 2020-07-20 16:43 Anonymous (not verified) 97.64.164.30 Bernard L. Gradoville D.D.S. Proprietorship 2800 Ingersoll Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Bernard Gradoville bgradoville@ingersollfamilydentistry.com Des Moines IA United States Tricia Wilson Jack Gradoville Signed (1) The employer does not elect the employers’ liability coverage. Bernard Gradoville bgradoville@ingersollfamilydentistry.com self Des Moines IA United States Tricia Wilson Jack Gradoville Signed
1135 2022-05-31 12:06 Anonymous (not verified) 174.215.227.133 Plagman Transportation Limited Liability Company 1306 Main St, Adel, Ia. 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-31 Ryan Plagman rplagman@gmail.com Adel Dallas Ia Chris Christensen Jack Ruby Signed (1) The employer does not elect the employers’ liability coverage. Ryan Plagman rplagman@gmail.com Same Adel Dallas Ia Chris Christensen Jack Ruby Signed
1937 2023-12-04 17:42 Anonymous (not verified) 94.188.205.174 Albert Schwartz Proprietorship 2250 Hwy 1 Sw 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. 2023-12-04 Albert Schwartz sageburnner100@msn.com Kalona Johnson Iowa Laura Schwartz Jackie Etheredge Signed (1) The employer does not elect the employers’ liability coverage. Albert Schwartz sageburnner100@msn.com Myself Kalona Johnson Iowa Laura Schwartz Jackie Etheredge Signed
1345 2022-10-25 15:25 Anonymous (not verified) 166.181.82.169 Estling Junk and Garbage Removal Limited Liability Company 660 West Main Street Apt.5 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-10-25 Jacob Steven Estling JacobEstling1@gmail.com Maynard Fayette Iowa Jacob Estling Jacob Estling Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jacob Steven Estling jacobestling1@gmail.com Owner Maynard Fayette Iowa Jacob Estling Jacob Estling Signed
1121 2022-05-19 17:45 Anonymous (not verified) 107.115.239.35 KG Land works LLC Limited Liability Company P.O. Box 931Barnsdall Oklahoma 74002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-19 Keiven Brooke Slone keiven.slone@gmail.com Barnsdalll Osage OK Colton Kelley Dalton Gardner Signed (1) The employer does not elect the employers’ liability coverage. Colton Kelley kglandworks@gmail.com Owner Barnsdalll Osage OK Dalton Garder Jacob Kelley Signed
2013 2024-01-31 15:14 Anonymous (not verified) 94.188.205.167 Aspen Ridge LLC Limited Liability Company 1404 G Ave Marengo, IA 52301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Jeffrey McKusker jeff@mckuskerelectric.com Marengo Iowa Iowa Karly Kovar Jacob McKusker Signed (1) The employer does not elect the employers’ liability coverage. Lori McKusker jeff@mckuskerelectric.com Spouse Mead Weld Colorado Karly Kovar Jacob McKusker Signed
2014 2024-01-31 15:17 Anonymous (not verified) 94.188.205.174 Aspen Ridge LLC Limited Liability Company 1404 G 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. 2023-05-10 Lori McKusker lori@mckuskerelectric.com Mead Weld Colorado Karly Kovar Jacob McKusker Signed (1) The employer does not elect the employers’ liability coverage. Lori McKusker jeff@mckuskerelectric.com Self Mead Weld Colorado Karly Kovar Jacob McKusker Signed
579 2021-07-20 12:37 Anonymous (not verified) 166.205.124.133 M&M HOME IMPROVEMENT Limited Liability Company 5406 28th Ave. Moline , IL 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-07-20 Jarred Alexander bookkyddjay@gmail.com Moline USA IL Jacob Nagel Jacob Nagel Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jarred Alexander bookkyddjay@gmail.com Same Moline USA IL Jacob Nagel Jacob Nagel Signed
1325 2022-10-02 20:07 Anonymous (not verified) 50.80.107.101 Hanson Custom Cleanup and Removal LLC Limited Liability Company 1221 Fleur Dr. Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-02 Jason Jacob Hanson jasonhanson1985@gmail.com Waterloo Blackhawk Iowa Cindy Shreve Jacob Ring Signed (1) The employer does not elect the employers’ liability coverage. Jason Hanson jasonhanson1985@gmail.com Self Waterloo Blackhawk Iowa Cindy Shreve Jacob Ring Signed
993 2022-03-22 10:36 Anonymous (not verified) 173.18.6.21 Clay Winkelmann Proprietorship 1652 227th Street, Fontanelle, IA 50846 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-22 Clay Winkelmann crwwproperties@gmail.com Fontanelle Adair Iowa Kathryn Larson Jacob Tiernan Signed (1) The employer does not elect the employers’ liability coverage. Clay Winkelmann crwwproperties@gmail.com Owner Fontanelle Adair Iowa Kathryn Larson Jacob Tiernan Signed
1009 2022-03-28 07:24 Anonymous (not verified) 173.18.6.21 Clay Windelmann Limited Liability Company 362 Public Square, Greenfield, IA 50849 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 C;ay Winkelman crwwproperties@gmail.com Fontanelle Adair Iowa Kathryn Larson Jacob Tiernan Signed (1) The employer does not elect the employers’ liability coverage. Clay Winkelmann crwwproperties@gmail.com Owner/Self Fontanelle Adair Iowa Kathryn Larson Jacob Tiernanq Signed
1795 2023-08-11 08:02 Anonymous (not verified) 94.188.205.176 Overall Cleaning Proprietorship 507 Enterprise Ct #6 Independence IA 50644 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-11 Michelle L. Vonsprecken michelle.vonsprecken@gmail.com Independence Buchanan Iowa Jacob Von Sprecken Cody Caraway Signed (1) The employer does not elect the employers’ liability coverage. Justin C Hayes overallcleaning21@gmail.com Business Partner Marion Linn IA Cody Caraway Jacob Von Sprecken Signed
2026 2024-02-07 08:32 Anonymous (not verified) 94.188.205.169 Strong Fencing & Decking LLC Limited Liability Company 343 59th Street Des Moines Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jacob James Strong strongfencingdecking@gmail.com Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed (1) The employer does not elect the employers’ liability coverage. Jacob Strong strongfencingdecking@gmail.com Owner Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed
945 2022-03-04 10:15 Anonymous (not verified) 97.125.39.88 Solid Solutions Caulking LLC. Limited Liability Company 1011 N. Ankeny Blvd P.O. Box 216. 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. 2022-03-04 Jesse Guilford sscaulking@yahoo.com Ankeny Polk Iowa Jesse Guilford Jade Guilford Signed (1) The employer does not elect the employers’ liability coverage. Jade Guilford sscaulking@yahoo.com Secratary Ankeny Polk Iowa Jesse Guilford Jade Guilford Signed
1419 2023-01-12 09:27 Anonymous (not verified) 71.34.173.44 Solid Solutions Caulking LLC. Limited Liability Company 1011 N. Ankeny BLVD Po Box 216 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. 2023-01-01 Jesse Guilford sscaulking@yahoo.com Ankeny Polk Iowa Jesse Guilford Jade Guilford Signed (1) The employer does not elect the employers’ liability coverage. Jesse Guilford sscaulking@yahoo.com Self Ankeny Polk Iowa Jesse Guilford Jade Guilford 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
854 2022-01-24 19:59 Anonymous (not verified) 217.180.228.216 Hansen Installations Limited Liability Company 109 NW Calista 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. 2022-01-24 Brian D Hansen bdhansen33@gmail.com Grimes IA United States Laurie Mills Jaiden Nelson Signed (1) The employer does not elect the employers’ liability coverage. Brian D Hansen bdhansen33@gmail.com Self Grimes IA United States Laurie Mills Jaiden Nelson Signed
1775 2023-08-03 09:37 Anonymous (not verified) 94.188.207.227 J j builder llc Limited Liability Company 2307 richland dr des moines 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. 2023-07-28 José Cruz Jasso balleza jassoprimo03@icloud.com Des moines Polk Iowa Jaime Rodrigues Mario ramos Signed (1) The employer does not elect the employers’ liability coverage. Irving iibarra@centroinsurance.com Agent Des moines Polk Iowa Irving Ibarra Jaime Rodrigues Signed
573 2021-07-14 09:12 Anonymous (not verified) 166.181.83.201 Dustin Demoss Proprietorship 407 mechanic st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-13 Dustin Michael DeMoss dustindemoss14@gmail.com Monmouth Iowa United States Jake Jake Signed (1) The employer does not elect the employers’ liability coverage. Dustin Michael DeMoss dustindemoss14@gmail.com Idk Monmouth Iowa United States Jake Jake Signed
207 2020-07-16 13:05 Anonymous (not verified) 173.16.140.254 Steve Kennedy Proprietorship 5108 SW 13th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-16 Steve Kennedy stevekennedy@gmail.com Des Moines Polk Iowa Jen Echterling Jake Hibbert Signed (1) The employer does not elect the employers’ liability coverage. Steve Kennedy stevekennedy007@gmail.com Owner Des Moines Polk Iowa Jen Echterling Jake Hibbert Signed
253 2020-09-09 12:27 Anonymous (not verified) 173.18.16.129 H E Drywall INC Proprietorship 200 E Lally St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-09 Eriberto Castro hedrywall82@gmail.com Des Moines Polk Iowa Lesa Reeves Jake Hibbert Signed (1) The employer does not elect the employers’ liability coverage. eriberto castro hedrywall82@gmail.com owner Des Moines Polk Iowa Lesa Reeves Jake Hibbert Signed
1950 2023-12-12 12:20 Anonymous (not verified) 94.188.205.168 Central Iowa Welding & Repair Limited Liability Company 13913 140th 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. 2023-01-01 Trevor Campbell centraliowaweldingrepair@gmail.com Indianola Warren Iowa Amber Campbell Jake Snow Signed (1) The employer does not elect the employers’ liability coverage. Trevor Campbell centraliowaweldingrepair@gmail.com Owner Indianola Warren Iowa Amber Campbell Jake Snow Signed
2098 2024-03-15 18:38 Anonymous (not verified) 94.188.205.177 OMG Bros, LLC Limited Liability Partnership 404 Ivanhoe Rd, Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-03-15 Oscar Omar Gaytan og210666@gmail.com Waterloo Black Hawk Iowa Kaden Lyle Jake Usher Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Tristan Anthony Siebrands omgservices@omgbros.org Partner Waterloo Black Hawk Iowa Kaden Lyle Jake Usher Signed
2173 2024-04-23 14:19 Anonymous (not verified) 94.188.205.166 Duer and Sons Remodeling, Inc Partnership 1795 Se 82nd St, Runnells Iowa 50237 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-23 John Duer John@duerandsonsremodeling.com Runnells Polk Iowa Travis Justice Jake VanGorp Signed (1) The employer does not elect the employers’ liability coverage. John Duer John@duerandsonsremodeling.com Owner Runnells Polk Iowa Travis Justice Jake VanGorp Signed
1667 2023-05-29 22:31 Anonymous (not verified) 94.188.207.226 All J Acres Limited Liability Company 13522 120th Ave, Ottumwa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-26 Jonathan Bunt jonbunt@gmail.com Ottumwa Wapello IA James Williamson James Ash Signed (1) The employer does not elect the employers’ liability coverage. Jonathan Bunt jonbunt@gmail.com Self Ottumwa Wapello IA James Williamson James Ash Signed
15 2019-12-30 18:13 Anonymous (not verified) 104.166.243.52 Matt Moore Proprietorship 8450 Hickman Road #15C I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-30 Matt Moore mljm2016@outlook.com Clive Iowa Iowa Tom Onnen James Buffington Signed (1) The employer does not elect the employers’ liability coverage. Matt Moore mljm2016@outlook.com Subcontractor Urbandale IOWA United States Tom Onnen James Buffington Signed
1494 2023-03-06 08:23 Anonymous (not verified) 94.188.207.223 James Douglas Clemons Proprietorship 3807 SW 3rd 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 james clemons james.clemons@grandview.edu des moines Iowa United States james clemons james clemons Signed (1) The employer does not elect the employers’ liability coverage. james clemons james.clemons@grandview.edu myself des moines Iowa United States james clemons james clemons Signed
1768 2023-07-29 11:10 Anonymous (not verified) 94.188.207.223 Makana Industries LLC Limited Liability Company 1800 Grand Ave #352, 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. 2023-07-29 Matthew Akana mandiremod515@gmail.com West Des Moines Polk Iowa Catherine Sobrado James Fowler Signed (1) The employer does not elect the employers’ liability coverage. Rocket Lawyer Corporate Services LLC mandiremod515@gmail.com Registered agent Des Moines Polk Iowa Catherine Sobrado James Fowler Signed
1222 2022-07-21 16:01 Anonymous (not verified) 66.129.208.246 James J Stallman Proprietorship 190 BLUFF DR, Fairfax, IA 52228 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 James J Stallman stallmanjim@aol.com FAIRFAX IA United States James J Stallman James J Stallman Signed (1) The employer does not elect the employers’ liability coverage. Lundahl, Hatt, Austad Tax Services Inc NN@LHAtax.com President Marion Linn IA James J Stallman James J Stallman Signed
1572 2023-04-13 11:12 Anonymous (not verified) 94.188.205.167 CK Trucking Proprietorship 24497 Hayes Street, Pleasantville, Iowa 50225 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-13 Craig Kooyman dmsstumpguy@yahoo.com Pleasantville IA IA Chad Randleman James Jordan Signed (1) The employer does not elect the employers’ liability coverage. Craig Kooyman dmsstumpguy@yahoo.com Owner Pleasantville Warren IA Chad Randleman James Jordan Signed
2058 2024-02-26 16:32 Anonymous (not verified) 94.188.207.224 performance gutter Proprietorship PO BOX 306, NORWALK IOWA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-26 RICHARD BAINTER RWBNJ50@AOL.COM NORWALK WARREN IOWA DYLAN LANE JAMES LANE Signed (1) The employer does not elect the employers’ liability coverage. RICHARD BAINTER RWBNJ50@AOL.COM OWNER NORWALK WARREN IOWA DYLAN LANE JAMES LANE Signed
680 2021-10-18 13:58 Anonymous (not verified) 166.181.86.88 Gerald Jerome Proprietorship 2668 Wapsi Ridge Dr. Walker, IA 52352 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-18 Gerald Jerome geraldjerome373@ymail.com Walker IA United States Benjamin J Barkalow James M. Barkalow Signed (1) The employer does not elect the employers’ liability coverage. Gerald Jerome geraldjerome373@ymail.com Self employed Walker Linn Iowa Benjamin J Barkalow James M Barkalow Signed
296 2020-10-29 09:39 Anonymous (not verified) 174.243.81.9 Alex Vanderbeek Proprietorship 85 NE Grace Wood Drive, Waukee, Iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-29 Alex Vanderbeek Vanderbeek17151@gmail.com Waukee Dallas Iowa Joe Simpson James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Alex Vanderbeek Vanderbeek17151@gmail.com self WAUKEE IA United States Joe Simpson James Nelson Signed
302 2020-10-31 13:04 Anonymous (not verified) 173.17.230.149 Absolute Construction Partnership 3720 Patricia Drive, Urbandale, Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 Joe Simpson jrsimpson27@gmail.com Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Joe Simpson jrsimpson27@gmail.com self Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed
304 2020-10-31 13:23 Anonymous (not verified) 173.17.230.149 Jerome Jones Proprietorship 5203 Douglas Avenue, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 Jerome Jones jeromepops1@gmail.com Des Moines Polk IA Joe Simpson James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Jerome Jones jeromepops1@gmail.com self Des Moines Polk IA Joe Simpson James Nelson Signed
1188 2022-07-07 11:24 Anonymous (not verified) 107.117.176.70 Pitts Aerial Services LLC Limited Liability Company 2478 county road 1488 Cullman al 35058 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Owner Cullman Cullman AL Sydney Pitts James Robertson Signed
1189 2022-07-07 11:50 Anonymous (not verified) 71.91.55.59 Austin Branch Pitts Proprietorship 2478 county road 1488 Cullman al 35058 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Proprietor Cullman Cullman AL Sydney Pitts James Robertson Signed
1210 2022-07-18 08:15 Anonymous (not verified) 173.22.187.234 Cardinal Rule Handyman Services, LLC Limited Liability Company 1304 E 10th St S, 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. 2022-07-18 James Andrew Dunlap cardinarulehandyman@gmail.com Newton Jasper Iowa Jacinda Marie Dunlap James Thornton Dunlap Signed (1) The employer does not elect the employers’ liability coverage. James Andrew Dunlap cardinalrulehandyman@gmail.com I am the authorized agent Newton Jasper Iowa Jacinda Marie Dunlap James Thornton Dunlap Signed
58 2020-02-10 21:18 Anonymous (not verified) 75.162.11.63 Moni tile Services llc Limited Liability Company 2207 E Walnut St des Moines iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-01 Monica M Sandoval Mjsandoval20@yahoo.com Des Moines Polk United States Cassie Ann bentz James wesley harkert Signed (1) The employer does not elect the employers’ liability coverage. Moni tile services llc Mjsandoval20@yahoo.com Self Des Moines Polk Iowa Cassie Ann bentz James wesley harkert Signed
1860 2023-10-04 14:31 Anonymous (not verified) 94.188.207.229 Raymond Osbon Proprietorship 1634 Park Towne LN 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. 2023-10-04 Raymond Earl Osbon rozbon999@gmail.com Cedar Rapids Linn Iowa Brandon Gibbs Jamie Fisher Signed (1) The employer does not elect the employers’ liability coverage. Raymond Earl Osbon rozbon999@gmail.com Myself Cedar Rapids Linn Iowa Brandon Gibbs Jamie Fisher Signed
413 2021-02-24 16:21 Anonymous (not verified) 199.120.93.40 Nelson Tire Recycling LLC Limited Liability Company 2270 Farley Rd Cascade Iowa 52033 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-02-24 Richard A Nelson nelsontirerecycling@gmail.com Cascade Dubugue Iowa Wendy Bergfeld Jan Elhinger Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Richard nelsontirerecycling@gmail.com Owner/officer Cascade Dubugue Iowa Wendy Bergfeld Jan Ehlinger Signed
952 2022-03-05 18:23 Anonymous (not verified) 108.59.100.21 Heaven Sent PC LLC Limited Liability Company 604 Allamakee St, Waukon,IA 52172 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-01 Justin Piggott heavensentpetcremation@gmail.com Waukon Allamakee Iowa Kaia Piggott Jane M Regan Signed (1) The employer does not elect the employers’ liability coverage. Justin Piggott heavensentpetcremation@gmail.com Member of LLC Waukon Allamakee Iowa Kaia Piggott Jane M Regan Signed
1677 2023-06-02 11:37 Anonymous (not verified) 94.188.207.230 Karl Klotzbach Proprietorship 403 Jefferson, Decorah IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-02 Karl Klotzbach kdklotzbach@gmail.com Decorah Winneshiek Iowa Robin Schultz Jane Regan Signed (1) The employer does not elect the employers’ liability coverage. Karl Klotzbach kdklotzbach@gmail.com Employer Decorah Winneshiek Iowa Robin Schutlz Jane M Regan Signed
1507 2023-03-09 08:16 Anonymous (not verified) 94.188.207.230 Greufe Construction Proprietorship 2820 230th 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. 2023-01-01 Wayne Greufe wgreufe@wmtel.net Blairsburg US United States Janet Greufe Janet Greufe Signed (1) The employer does not elect the employers’ liability coverage. Wayne Greufe wgreufe@wmtel.net Friend Blairsburg US United States Janet Greufe Janet Greufe Signed
855 2022-01-26 10:39 Anonymous (not verified) 209.152.66.250 Robert L Stutzman Limited Liability Company 33784 Hwy 22 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-26 Robert L Stutzman bnbstutzman@gmail.com Keota Iowa United States Dasha Hesseltine Janette Miller Signed (1) The employer does not elect the employers’ liability coverage. Sandra Stutzman iafarmgirl90@gmail.com Daughter Keota Iowa United States Dasha Hesseltine Janette Miller Signed
461 2021-04-06 08:49 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-06 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
462 2021-04-06 08:56 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven,IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-06 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
975 2022-03-15 10:34 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
976 2022-03-15 10:44 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
1516 2023-03-14 09:00 Anonymous (not verified) 94.188.207.225 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-14 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
1517 2023-03-14 09:06 Anonymous (not verified) 94.188.207.230 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-14 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
2140 2024-04-09 09:28 Anonymous (not verified) 94.188.205.175 Bart Fuller& James Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven PAlo Alto Iowa Kathryn Kelley Janice Henningsen Signed
2141 2024-04-09 09:34 Anonymous (not verified) 94.188.205.177 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed
2142 2024-04-09 09:39 Anonymous (not verified) 94.188.205.167 Bart Fuller & james Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 James Fuller goffins@ruthventel.com Ruthven Pal Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed
978 2022-03-15 12:42 Anonymous (not verified) 173.24.17.213 Jose Antonio Hernández Tobar Limited Liability Company 219 Huisman Cir I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Jose Antonio Hernandez Tobar josehernanr5@icloud.com Marshalltown Marshall Iowa Cindy Garcia Hernandez Jaquelin Garcia Barajas Signed (1) The employer does not elect the employers’ liability coverage. Jose Antonio Hernandez Tobar josehernanr5@icloud.com Self Marshalltown Marshall Iowa Cindy Garcia Hernandez Jaquelin Garcia Barajas Signed
466 2021-04-08 09:58 Anonymous (not verified) 216.81.153.249 Supreme Express Transport LLC Limited Liability Company 609 Euclid Ave, Cherokee, IA 51012 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-10 Liana Gil liana2702@gmail.com Cherokee Cherokee Iowa Leigh Laven Jared Brashears Signed (1) The employer does not elect the employers’ liability coverage. Liana Gill liana2702@gmail.com Owner Cherokee Cherokee Iowa Leigh Laven Jared Brashears Signed
1576 2023-04-17 08:32 Anonymous (not verified) 94.188.205.167 Reece Wilson Limited Liability Company 1431 Starbeck Circle I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-14 Reece J Wilson rjwilson030@gmail.com Cedar Falls Blackhawk Iowa Kendall Cotant Darryl Mason Signed (1) The employer does not elect the employers’ liability coverage. John Richter jrichter@beecherlaw.com Business Waterloo Blackhawk Iowa Kendall Cotant Jared Hottle Signed
966 2022-03-11 10:04 Anonymous (not verified) 173.19.189.168 Steger Siding & Construction Limited Liability Company 1020 25th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-11 Jared Steger jared.steger@gmail.com Marion IA United States Jared Steger Jared Steger Signed (1) The employer does not elect the employers’ liability coverage. Jared Steger jared.steger@gmail.com self Marion IA United States Jared Steger Jared Steger Signed
1076 2022-04-28 13:14 Anonymous (not verified) 149.20.212.228 Van Ginkel Farms LLC Limited Liability Company 2745 Chestnut Ave Inwood, IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 James Van Ginkel bonnievanginkel@gmail.com Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed (1) The employer does not elect the employers’ liability coverage. James VanGinkel bonnievanginkel@gmail.com self Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed
1077 2022-04-28 13:16 Anonymous (not verified) 149.20.212.228 Van Ginkel Farms LLC Limited Liability Company 2745 Chestnut Ave Inwood, IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Bonnie VanGinkel bonnievanginkel@gmail.com Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed (1) The employer does not elect the employers’ liability coverage. James VanGinkel bonnievanginkel@gmail.com owner Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed
1618 2023-04-28 11:10 Anonymous (not verified) 94.188.205.167 Hunter Flying Service, LLC Limited Liability Company PO Box 215 Hunter, AR 72074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-28 James Lynn Cary hunterflying@att.net Hunter Woodruff Arkansas Karen Gifford Jason White Signed (1) The employer does not elect the employers’ liability coverage. James Lynn Cary hunterflying@att.net Self Hunter Woodruff AR Karen Gifford Jason White Signed
1246 2022-08-08 12:33 Anonymous (not verified) 174.215.249.59 Dustin Rambo Proprietorship 4570, Hunter 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. 2022-08-07 Dustin Lee Rambo dlrambo80@gmail.com Palo USA IA Matt Lytle Jason Achenbach Signed (1) The employer does not elect the employers’ liability coverage. Dustin Rambo dlrambo80@gmail.com Self Palo USA IA Matt Lytle Jason Achenbach Signed
365 2021-01-15 11:24 Anonymous (not verified) 63.227.74.126 Paramount Kitchen and Bath Limited Liability Company 2155 SE 37TH ST STE C I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-15 Michael Simpson mike@paramount-kitchens.com GRIMES Iowa United States Cory Morris Jason Andersen Signed (1) The employer does not elect the employers’ liability coverage. Michael Simpson mike@paramount-kitchens.com Owner GRIMES Iowa United States Cory Morris Jason Andersen Signed
584 2021-07-23 15:38 Anonymous (not verified) 75.162.41.54 Bradens Roofing & Construction LLc Limited Liability Company 2450 Hart Ave, Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-23 Arsenio Vargas avargas409@gmail.com Des Moines Polk Iowa Marc Black Jason Anderson Signed (1) The employer does not elect the employers’ liability coverage. Arsenio Vargas avargas409@gmail.com Owner Des Moines Polk Iowa Marc Black Jason Anderson Signed
2081 2024-03-08 10:44 Anonymous (not verified) 94.188.205.167 T & S Sandblasting and Painting LLC Limited Liability Company 101 Clinton ST Corwith IA 50430 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Matthew Tindall matt.tindall83@gmail.com Corwith Hancock IA Wendy S Jensen Jason Bradley Signed (1) The employer does not elect the employers’ liability coverage. Matthew Tindall matt.tindall83@gmail.com self Corwith Hancock IA Wendy S Jensen Jason Bradley Signed
2082 2024-03-08 10:47 Anonymous (not verified) 94.188.205.176 T & S Sandblastin and Painting LLC Limited Liability Company 101 Clinton ST Corwith IA 50430 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Robert Schissel matt.tindall83@gmail.com Corwith Hancock Iowa Wendy S Jensen Jason Bradley Signed (1) The employer does not elect the employers’ liability coverage. Robert Schissel matt.tindall83@gmail.com self Corwith Hancock Iowa Wendy S Jensen Jason Bradley Signed
1015 2022-03-29 10:56 Anonymous (not verified) 129.255.1.117 Alli Center Proprietorship 1150 5th St Suite 270 Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Miranda K Maday miranda.maday@alli-center.com North Liberty Johnson Iowa Zara Wanlass Jason Knight Signed (1) The employer does not elect the employers’ liability coverage. Zara Wanlass zara.wanlass@alli-center.com Co-Owner and Business Manager Iowa City Johnson IA Miranda K Maday Jason Knight Signed
1194 2022-07-08 13:12 Anonymous (not verified) 174.45.15.103 307 Safety LLC Limited Liability Company 9 Trinidad CT Gillette, WY 82716 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-08 Joshua Peter Tompkins JTompkins@307Safety.com Gillette Campbell Wyoming Paul Prather Jason Praus Signed (1) The employer does not elect the employers’ liability coverage. Joshua Peter Tompkins JTompkins@307Safety.com Owner Gillette Campbell Wyoming Paul Prather Jason Praus Signed
1230 2022-07-27 08:59 Anonymous (not verified) 108.217.146.87 Hunter Flying Service Limited Liability Company PO Box 215 Hunter, AR 72074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-27 Lynn Cary hunterflying@att.net Hunter Woodruff United States Karen Gifford Jason White Signed (1) The employer does not elect the employers’ liability coverage. Lynn Cary hunterflying@att.net Owner Hunter AR United States Karen Gifford Jason White Signed
1231 2022-07-27 11:59 Anonymous (not verified) 108.217.146.87 Adam Towe Proprietorship 26 Reeves Rd Hartselle, AL 35640 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-27 Adam Towe adamtowe99@gmail.com Hartselle Morgan AL Lynn Cary Karen Gifford Signed (1) The employer does not elect the employers’ liability coverage. Hunter Flying Service hunterflying@att.net Owner Hunter AR United States Karen Gifford Jason White 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
407 2021-02-18 10:47 Anonymous (not verified) 165.225.61.119 Ryan Myers Painting Proprietorship 836 25th St Rock Island, IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-21 Ryan Myers tickspoon@yahoo.com Rock Island Rock Island IL Seth Rowland Jay Romeo Signed (1) The employer does not elect the employers’ liability coverage. Ryan Myers tickspoon@yahoo.com Self Rock Island Rock Island IL Seth Rowland Jay Romeo Signed
408 2021-02-18 10:51 Anonymous (not verified) 165.225.61.119 Brandon Anderson Painting Proprietorship 608 30th St Rock Island, IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-21 Brandon Anderson banderson792@gmail.com Rock Island Rock Island IL Seth Rowland Jay Romeo Signed (1) The employer does not elect the employers’ liability coverage. Brandon Anderson banderson792@gmail.com Self Rock Island Rock Island IL Seth Rowland Jay Romeo Signed
1611 2023-04-27 09:21 Anonymous (not verified) 94.188.205.168 powell express moving Proprietorship 2600 Marquette Pl 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. 2023-04-27 Roger Powell powellexpressmoving@gmail.com Dubuque Dubuque Iowa Connie Powell Jay Weiser Signed (1) The employer does not elect the employers’ liability coverage. Roger Powell powellexpressmoving@gmail.com Self Dubuque Dubuque Iowa Connie Powell Jay Weiser Signed
1479 2023-02-24 08:34 Anonymous (not verified) 94.188.207.229 Sedenka Excavating and Habitat Limited Liability Partnership 204 Meadowview Drive, Lisbon, IA 52253 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Trey Sedenka SedenkaEH@gmail.com Lisbon Cedar Iowa Robert Cummings Jayson Wallace Signed (1) The employer does not elect the employers’ liability coverage. Trey Sedenka SedenkaEH@gmail.com Owner Lisbon Cedar Iowa Robert Cummings Jayson Wallace Signed
1209 2022-07-17 16:41 Anonymous (not verified) 166.181.86.161 JustbelieveCreationsllc Limited Liability Company 104 East Chestnut Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-17 Joshua Riera-Gomez josh.gomez.com@gmail.com Garnavillo IA United States Eric Jarman Jean brandt Signed (1) The employer does not elect the employers’ liability coverage. Joshua Riera-Gomez josh.gomez.com@gmail.com Myself Garnavillo IA United States Eric jarman Jean brandt Signed
816 2021-12-30 09:56 Anonymous (not verified) 174.199.83.133 Michael Fales Proprietorship 1987 180th Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-30 Michael Lee Fales Chubby__69@hotmail.com Canby Yellow Medicine Minnesota Tori Fales Jean Fales Signed (1) The employer does not elect the employers’ liability coverage. Michael Lee Fales Chubby__69@hotmail.com Owner Canby Yellow Medicine Minnesota Tori Fales Jean Fales Signed
1471 2023-02-20 10:24 Anonymous (not verified) 94.188.205.169 Vega Investments Limited Liability Company 330 NE 72nd Street, 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. 2023-02-20 Stephanie Westrom stephanie.westrom@microsoft.com Pleasant Hill Polk Iowa Thomas Westrom Jean Schnake Signed (1) The employer does not elect the employers’ liability coverage. Stephanie Westrom stephanie.westrom@microsoft.com Owner Pleasant Hill Polk Iowa Thomas Westrom Jean Schnake Signed
1767 2023-07-28 14:31 Anonymous (not verified) 94.188.207.229 Kleckner Backhoe Service Proprietorship 1302 S 1st St, Osage, IA 50461 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-28 Tracy S Kleckner terridkleckner@hotmail.com Osage Mitchell Iowa Robin Tabbert Jeannie Lemke Signed (1) The employer does not elect the employers’ liability coverage. L R Falk Construction Co jeannie@lrfalk.com Dump Truck Hauler Osage Mitchell Iowa Robin Tabbert Jeannie Lemke Signed
1107 2022-05-16 15:28 Anonymous (not verified) 64.33.230.163 hangar 8 spray service Limited Liability Company 1626 airport 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. 2022-05-16 jed douglas hansen hangar.8@hotmail.com Clark South Dakota United States jed douglas hansen jed douglas hansen Signed (1) The employer does not elect the employers’ liability coverage. jed douglas hansen hangar.8@hotmail.com contract Clark South Dakota United States Jed Hansen Jed Hansen Signed
1110 2022-05-17 11:17 Anonymous (not verified) 64.33.230.163 Jed Hansen Proprietorship 1626 Airport 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. 2022-05-17 Jed Douglas Hansen hangar.8@hotmail.com Clark Clark South Dakota Jed Hansen Jed Hansen Signed (1) The employer does not elect the employers’ liability coverage. Jed Hansen hangar.8@hotmail.com Proprietor Clark Clark South Dakota Jed Hansen Jed Hansen Signed
1111 2022-05-17 11:18 Anonymous (not verified) 64.33.230.163 Jed Hansen Proprietorship 1626 Airport 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. 2022-05-17 Jed Douglas Hansen hangar.8@hotmail.com Clark Clark South Dakota Jed Hansen Jed Hansen Signed (1) The employer does not elect the employers’ liability coverage. Jed Hansen hangar.8@hotmail.com Proprietor Clark Clark South Dakota Jed Hansen Jed Hansen Signed
1504 2023-03-07 18:38 Anonymous (not verified) 94.188.207.227 Mathias Heating & Cooling Limited Liability Company 1449 19th Pl West Des Moines, 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. 2023-03-07 Justin Mathias emathiasj@gmail.com West Des Moines Polk Iowa Jesse Parker Jeff Boucher Signed (1) The employer does not elect the employers’ liability coverage. Justin Mathias emathiasj@gmail.com Member West Des Moines Polk Iowa Jesse Parker Jeff Boucher Signed
529 2021-05-24 16:16 Anonymous (not verified) 67.230.239.111 Olsem Aerial Application Services LLC Limited Liability Company 34538 County Road 13 Westbrook, Minnesota 56183 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-24 Benjamin Olsem oaasllC@gmail.com Westbrook Cottonwood Minnesota Megan Olsem Jeff Oberg Signed (1) The employer does not elect the employers’ liability coverage. Olsem Aerial Application Services LLC oaasllc@gmail.com Owner/Self Westbrook Cottonwood Minnesota Megan Olsem Jeff Oberg Signed
859 2022-01-27 11:29 Anonymous (not verified) 204.155.61.217 JD Drywall Proprietorship 503 9th Street Kalona, Iowa 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. 2022-01-27 John Duwa johnduwa@outlook.com Kalona Washington Iowa Angela Stutzman Jeff Spenner Signed (1) The employer does not elect the employers’ liability coverage. JD Drywall - John Duwa johnduwa@outlook.com owner Kalona Washington Iowa Angela Stutzman Jeff Spenner Signed
1876 2023-10-23 14:26 Anonymous (not verified) 94.188.205.169 Magnus, LLC Limited Liability Company 1120 2nd Street SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-23 Kristina Link magnina@aol.com Cedar Rapids IA IA Shannon Thompson Jeff Spies Signed (1) The employer does not elect the employers’ liability coverage. Kristina Link magnina@aol.com business owner Cedar Rapids Iowa Iowa Shannon Thompson Jeff Spies Signed
926 2022-02-17 15:20 Anonymous (not verified) 166.181.83.68 Staley Trucking LLC Limited Liability Company 1388 140th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-17 Travis Staley staleyracing121@gmail.com Hampton Franklin IA Tyler Staley Jeff Staley Signed (1) The employer does not elect the employers’ liability coverage. Travis Staley staleyracing121@gmail.com President Hampton Franklin IA Tyler Staley Jeff Staley Signed
1777 2023-08-03 14:21 Anonymous (not verified) 94.188.207.227 Mark Doty Proprietorship 509 Parwood Circle, 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. 2023-08-03 Mark Doty mdoty@dakotagrown.com Huxley Story IA Rebecca R Moeller Jeffery F Vanasse Signed (1) The employer does not elect the employers’ liability coverage. Rebecca R Moeller Becky@northernlines.net Agent Fairmont MN United States Rebecca R Moeller Jeffery F Vanasse Signed
815 2021-12-28 12:29 Anonymous (not verified) 173.29.239.122 Comtek, Inc. Proprietorship 3702 NW 13th St. Ankeny, Iowa 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-28 Micheal D. Qualley mqcomtek@gmail.com ANKENY IA United States Jacque Blackman Jeffery Keipper Signed (1) The employer does not elect the employers’ liability coverage. Jacque Blackman jblackman@grimesfinancialgroup.com client Grimes Polk Iowa Jacque Blackman Jeffery Keipper Signed
1824 2023-08-29 16:20 Anonymous (not verified) 94.188.205.176 Miller Construction Siding & Windows, LLC Limited Liability Company 3104 S.W. 26TH STREET, ANKENY, IA. 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-29 SCOTT MICHAEL DORAU SMD50021@GMAIL.COM Ankeny Polk United States Christopher Bohn Jeffrey Bohn Signed (1) The employer does not elect the employers’ liability coverage. SCOTT MICHAEL DORAU SMD50021@GMAIL.COM PRESIDENT Ankeny POLK United States CHRISTOPHER BOHN JEFFREY BOHN Signed
467 2021-04-10 12:21 Anonymous (not verified) 24.252.54.168 Dave and Nancy Preucil Inc. Proprietorship 13585 Clearview 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. 2021-04-10 Domenico Zurini II davesspeedwaydz@gmail.com Council Bluffs IA United States Irven Saar II Jeffrey Hanke Signed (1) The employer does not elect the employers’ liability coverage. Barbi Zurini bzurini@gmail.com Wife Council Bluffs IA United States Irven Saar II Jeffrey Hanke Signed
73 2020-02-21 13:44 Anonymous (not verified) 192.30.185.233 Viejos Masnry construction LLC Limited Liability Company 1708 Villa Ave. Sioux City IA 51103 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-13 Oscar Castro Ramirez veijosconstruction@gmail.com Sioux City Woodbury Iowa JEFFREY H MCCLINTOCK Nancy Fleming Signed (1) The employer does not elect the employers’ liability coverage. Viejos Masonry Construction LLC veijosconstruction@gmail.com Owner/President SIOUX CITY Woodbury Iowa Nancy Fleming Jeffrey Hugh McClintock Signed
1129 2022-05-26 13:34 Anonymous (not verified) 172.58.227.18 Jonathan M Ramirez Proprietorship 834 20th STREET SE. Cedar Rapids IA 53403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-26 Jonathan M Ramirez jon.hodgecma@gmail.com Cedar Rapids Linn IA Audrey Randle-EL Jeffrey M Ramirez Jr. Signed (1) The employer does not elect the employers’ liability coverage. Jonathan Ramirez linncountyramirez@gmail.com Owner Cedar Rapids Linn Iowa Audrey Randle-EL Jeffrey Ramirez Jr Signed
1130 2022-05-26 13:34 Anonymous (not verified) 172.58.227.18 Jonathan M Ramirez Proprietorship 834 20th STREET SE. Cedar Rapids IA 53403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-26 Jonathan M Ramirez jon.hodgecma@gmail.com Cedar Rapids Linn IA Audrey Randle-EL Jeffrey M Ramirez Jr. Signed (1) The employer does not elect the employers’ liability coverage. Jonathan Ramirez linncountyramirez@gmail.com Owner Cedar Rapids Linn Iowa Audrey Randle-EL Jeffrey Ramirez Jr Signed
335 2020-12-08 11:08 Anonymous (not verified) 173.18.16.129 quintanillas construction llc Limited Liability Company 3136 6th ave des moines ia 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-08 maynor quintanilla maynorquintanilla42@gmail.com des moines polk Iowa Lesa Reeves Jen Lambert Signed (1) The employer does not elect the employers’ liability coverage. maynor quintanilla maynorquintanilla42@gmail.com owner des moines polk Iowa Lesa Reeves Jen Lambert Signed
494 2021-04-22 12:41 Anonymous (not verified) 173.18.16.129 Unique Drywall Finishing LLC Limited Liability Company 509 E 26th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-22 jose angel chavez uniquewal@yahoo.com Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed (1) The employer does not elect the employers’ liability coverage. Jose Angel Chavez uniquewal@yahoo.com owner Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed
1287 2022-08-30 13:11 Anonymous (not verified) 173.18.22.217 Gomez Painting Limited Liability Company 3609 56th St Des Moines IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-30 Orlyn Gomez orlyngomez9@gmail.com Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed (1) The employer does not elect the employers’ liability coverage. Orlyn Gomez orlyngomez9@gmail.com Owner Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed
291 2020-10-25 11:06 Anonymous (not verified) 208.126.69.94 self-employed Proprietorship PO Box 15, 430 E. Iowa 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. 2022-10-25 Steven Fisher fishersjk@gmail.com St. Mary's Iowa United States Jodi Fisher Jenna Fisher Signed (1) The employer does not elect the employers’ liability coverage. Steven Fisher fishersjk@gmail.com same person St. Mary's Iowa United States Jodi Fisher Jenna Fisher Signed
1934 2023-12-01 22:43 Anonymous (not verified) 94.188.207.224 wasabi johnston llc Limited Liability Company 7115 ridgedale ct, johnston, IA, 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-01 wenhui chen michaelchen@wasabidsm.com johnston polk Iowa wen Zheng Jenna Yu Signed (1) The employer does not elect the employers’ liability coverage. wenhui chen michaelchen@wasabidsm.com owner johnston polk IOWA wen zheng Jenna Yu Signed
2004 2024-01-28 12:41 Anonymous (not verified) 94.188.205.174 Wasabi Urbandale LLC Limited Liability Company 5106 155th Street, 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. 2024-01-28 Yean Ching Sue soamie@hotmail.com Urbandale Dallas Iowa Lina Zheng Jenna Yu Signed (1) The employer does not elect the employers’ liability coverage. Yean Ching Sue soamie@hotmail.com Owner Urbandale Dallas Iowa Lina Zheng Jenna Yu Signed
403 2021-02-16 11:20 Anonymous (not verified) 192.30.185.142 Rodrigo Ochoa Proprietorship 3310 5th St, Sioux City, IA 51105 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-16 Rodrigo Ochoa jesusochoa1976@icloud.com Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Rodrigo Ochoa jesusochoa1976@icloud.com Owner Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed
453 2021-03-26 08:27 Anonymous (not verified) 192.30.185.142 DYAD LLC Partnership 2308 Summit St, Sioux City, IA 51104 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-26 Andrew Glisar john@kellyconstruction.com Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Andrew Glisar john@kellyconstruction.com Owner/Partner Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed
382 2021-02-02 13:19 Anonymous (not verified) 192.30.185.142 Double D Weatherization Proprietorship 2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-02 Dale Gernhart lakehome@longlines.com Sergeant Bluff Woodbury IA Nate Blaeser Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Dale Gerhart lakehome@longlines.com Self Sergeant Bluff Woodbury IA Nate Blaeser Jennie Ebner Signed
808 2021-12-20 12:28 Anonymous (not verified) 107.77.209.143 Painting & Design Proprietorship 2728 51st Des Moines Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-20 John Eugene Herman jherman30@yahoo.com Des moines Polk Iowa Peggy Noplos Jennifer Herman Signed (1) The employer does not elect the employers’ liability coverage. John Herman jherman30@yahoo.com Self Des moines Polk Iowa Peggy Noplos Jennifer Herman Signed
498 2021-04-27 12:54 Anonymous (not verified) 173.31.147.225 TYREL KINKADE DBA: KINKADE CONSTRUCTION Proprietorship 2289 165TH ST UNIT 10D I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-21 TYREL KINKADE hogtyd97@yahoo.com SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. TYREL KINKADE JOEL@WALKERINSURANCEIA.COM SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
512 2021-05-11 13:12 Anonymous (not verified) 173.31.147.225 RUTHVEN ROCKS LLC Limited Liability Company 1205 ROLLING ST RUTHVEN IOWA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-11 JEFF CACEK JEFF@RUTHVENROCKS.COM RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JEFF CACEK joel@walkerinsuranceia.com MEMBER RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
513 2021-05-11 13:14 Anonymous (not verified) 173.31.147.225 RUTHVEN ROCKS LLC Limited Liability Company 1205 ROLLING ST RUTHVEN IOWA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-11 KEITH CACEK KEITH@RUTHVENROCKS.COM RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KEITH CACEK joel@walkerinsuranceia.com MEMBER RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
514 2021-05-11 13:16 Anonymous (not verified) 173.31.147.225 RUTHVEN ROCKS LLC Limited Liability Company 1205 ROLLING ST RUTHVEN IOWA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-11 MATT CACEK MATT@RUTHVENROCKS.COM MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MATT CACEK joel@walkerinsuranceia.com MEMBER MILFORD PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
670 2021-10-13 12:30 Anonymous (not verified) 173.19.179.111 MULLER TRANSPORT LLC Limited Liability Company 2083 260TH ST MILFORD, IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-13 PAUL MULLER MULLERTANSPORTLLC@GMAIL.COM MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. PAUL MULLER JOEL@WALKERINSURANCEIA.COM SELF MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1040 2022-04-12 09:36 Anonymous (not verified) 173.31.148.43 PAPA'S SMOKIN MEAT Proprietorship 1940 147TH ST SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-12 KEITH MORISTON PAPASSMOKINMEAT@GMAIL.COM MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KEITH MORISTON PAPASSMOKINMEAT@GMAIL.COM SELF MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1041 2022-04-12 09:39 Anonymous (not verified) 173.31.148.43 PAPA'S SMOKIN MEAT Proprietorship 1940 147TH ST SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-12 ROXANNE MORISTON MORISTON2@YAHOO.COM MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ROXANNE MORISTON MORISTON2@YAHOO.COM SELF MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1136 2022-05-31 13:46 Anonymous (not verified) 173.31.148.43 OKOBOJI BURRITO COMPANY LLC Limited Liability Company 39502 710TH ST LAKEFIELD, MN 56105 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-26 KATHRYN SCHULTZ kathrynlucier@ymail.com LAKEFIELD JACKSON MN JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KATHRYN SCHULTZ kathrynlucier@ymail.com SELF LAKEFIELD JACKSON MN JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1306 2022-09-13 15:50 Anonymous (not verified) 96.31.1.206 LUCIO PAINTING Proprietorship 818 W 4TH ST SPENCER, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-06 LUCIO PENA joel@walkerinsuranceia.com SPENCER CLAY IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. LUCIO PENA joel@walkerinsuranceia.com SELF SPENCER CLAY IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1439 2023-02-06 11:00 Anonymous (not verified) 96.31.1.206 L&C LLC Limited Liability Company 615 W 6TH ST ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 CARLOS MEDINA joel@walkerinsuranceia.com Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. CARLOS MEDINA joel@walkerinsuranceia.com SELF Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1476 2023-02-22 12:23 Anonymous (not verified) 94.188.205.174 KARL INGWERSEN Proprietorship 2716 FRANCIS SITES DR SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-22 KARL INGWERSEN KARL58INGWERSEN@GMAIL.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KARL INGWERSEN KARL58INGWERSEN@GMAIL.COM SELF SPIRIT LAKE DICKSINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1498 2023-03-07 11:20 Anonymous (not verified) 94.188.205.176 KATEN LLC Limited Liability Company 5100 S ASH GROVE AVE SIOUX FALLS, SD 57108 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 MIKE KLEIN joel@walkerinsuranceia.com SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MIKE KLEIN JOEL@WALKERINSURANCEIA.COM SELF SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1500 2023-03-07 11:22 Anonymous (not verified) 94.188.205.177 KATEN LLC Limited Liability Company 5100 S ASH GROVE AVE SIOUX FALLS, SD, 57108 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-27 MICHELLE KATEN JOEL@WALKERINSURANCEIA.COM SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MICHELE KATEN JOEL@WALKERINSURANCEIA.COM SELF SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORINGJ JENNIFER JANET YOUNGWIRTH Signed
1626 2023-05-05 11:16 Anonymous (not verified) 94.188.205.166 I HAWK BUILDERS LLC Limited Liability Company 1417 INDIAN HILLS DR SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-05 BEN BRANT babrant99@yahoo.com SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. BEN BRANT joel@walkerinsuranceia.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1790 2023-08-08 14:32 Anonymous (not verified) 94.188.205.166 NJ CONSTRUCTION LLC Limited Liability Company 4291 30TH AVE PETERSON, IA 51047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-08 NICHOLAS JAMES JONES njconstruction2014@hotmail.com PETERSON BUENA VISTA IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. NICHOLAS JAMES JONES njconstruction2014@hotmail.com SELF PETERSON BUENA VISTA IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1806 2023-08-17 11:37 Anonymous (not verified) 94.188.207.229 OKOBOJI TSHIRT CENTER LLC Limited Liability Company PO BOX 158 ARNOLDS PARK, IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-16 YACCOB SEBAN PACIFIC513@YAHOO.COM ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. YAACOB SEBAN PACIFIC513@YAHOO.COM SELF ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1838 2023-09-12 10:48 Anonymous (not verified) 94.188.207.224 OKOBOJI TSHIRT CENTER LLC Limited Liability Company PO BOX 158 ARNOLDS PARK, IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 ADIR SEBAN PACIFIC513@YAHOO.COM ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ADIR SEBAN PACIFIC513@YAHOO.COM SELF ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1850 2023-09-20 16:28 Anonymous (not verified) 94.188.207.225 JB DOCK SERVICE Limited Liability Company 1313 34TH ST SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-20 JONATHON BRUNSVOLD jbdockservice@gmail.com SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JONATHON BRUNSVOLD jbdockservice@gmail.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1863 2023-10-06 12:24 Anonymous (not verified) 94.188.207.223 ADRIAN CAZARES HERNANDEZ Proprietorship 409 N 16TH PL, ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-06 ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCE.COM ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCEIA.COM SELF ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1894 2023-11-03 10:02 Anonymous (not verified) 94.188.205.167 ASHLEY QUAIL DBA: RUSTIC ROOTS SALON Proprietorship 33596 SCHANY DR, RUTHVEN, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 ASHLEY QUAIL ashley-mazzanti@hotmail.com RUTHVEN PALO ALTO IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ASHLEY QUAIL ashley-mazzanti@hotmail.com SELF RUTHVEN PALO ALTO IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1941 2023-12-06 11:52 Anonymous (not verified) 94.188.205.167 GUEVARA CONCRETE LLC Limited Liability Company 26 WESTVIEW DR APT 5 MILFORD, IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 SAUL GUEVARA MEZA ESMEJ2513@GMAIL.COM MILFORD DICKINSON IA TAMI SUE KLEIN JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. SAUL GUEVARA MEZA ESMEJ2513@GMAIL.COM SELF MILFORD DICKINSON IA TAMI SUE KLEIN JENNIFER JANET YOUNGWIRTH Signed
1977 2024-01-05 13:25 Anonymous (not verified) 94.188.207.228 BOYOK BUILDS, LLC Limited Liability Company 25395 140TH ST, SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-04 VITALE BOYOK BOYOK68@GMAIL.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. VITALE BOYOK BOYOK68@GMAIL.COM SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1978 2024-01-08 13:28 Anonymous (not verified) 94.188.205.167 TYREL GIBSON Proprietorship 2004 CHICAGO AVE SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-08 TYREL GIBSON TY11TEKFALL@GMAIL.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. TYREL GIBSON TY11TEKFALL@GMAIL.COM SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
2073 2024-03-04 15:51 Anonymous (not verified) 94.188.207.227 JACOB HANSON Proprietorship 415 N 18TH ST ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-04 JACOB HANSON HANSONONEBOY@GMAIL.COM ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JACOB HANSON HANSONONEBOY@GMAIL.COM SELF ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
2115 2024-03-26 14:53 Anonymous (not verified) 94.188.207.223 DICKINSON COUNTY CLEANING AND MAINTENANCE, LLC Limited Liability Company 414 19TH ST PO BOX 182 SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-26 LISA ARROWOOD lisa.arrowood1126@gmail.com SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. LISA ARROWOOD lisa.arrowood1126@gmail.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
2157 2024-04-17 11:16 Anonymous (not verified) 94.188.205.168 LAKESIDE DETAILING LLC Limited Liability Company 249 EMERALD MEADOWS DR, ARNOLDS PARK, IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-17 DYLAN MCHUGH 19DMCHUGH@GMAIL.COM ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. DYLAN MCHUGH 19DMCHUGH@GMAIL.COM SELF ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
231 2020-08-13 18:22 Anonymous (not verified) 173.27.28.18 Kelley Contracting Proprietorship 115 Pinecrest Circle Elk Run Heights, Ia 50707 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-13 Chad Kelley chadkelley22@gmail.com Elk Run Heights Black Hawk Iowa Jack Kelley Jennifer Kelley Signed (1) The employer does not elect the employers’ liability coverage. Kelley Contracting chadkelley22@gmail.com Self Elk Run Heights Black Hawk Iowa Jack Kelley Jennifer Kelley Signed
916 2022-02-16 09:23 Anonymous (not verified) 173.18.22.217 Cesar Ponce Proprietorship 150 Aspen Dr. Norwalk IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-16 Cesar Ponce cesarponce00@icloud.com Nowalk Warren Iowa Lesa Reeves Jennifer Lambert Signed (1) The employer does not elect the employers’ liability coverage. Cesar Ponce cesarponce00@icloud.com Owner Norwalk Warren Iowa Lesa Reeves Jennifer Lambert Signed
1181 2022-07-06 10:10 Anonymous (not verified) 173.18.22.217 MB Masonry LLC Limited Liability Company PO Box 7534 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-06 Mirela Atajic mbmasonryllc@yahoo.com Urbandale Polk Iowa Lesa Reeves Jennifer Lambert Signed (1) The employer does not elect the employers’ liability coverage. Mirela Atajic mbmasonryllc@yahoo.com Owner Urbandale Polk Iowa Lesa Reeves Jennifer Lambert Signed
1865 2023-10-09 10:28 Anonymous (not verified) 94.188.205.166 Lori Martinez Proprietorship 6650 SE 5 TH STREET DES MOINES IA, 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-09 Lori Martinez azulbenavidez04@gmail.com Des Moines Polk Iowa R. Mitch Coluzzi Jennifer Lambert Signed (1) The employer does not elect the employers’ liability coverage. Lori Martinez azulbenavidez04@gmail.com Self Des Moines Polk Iowa R. Mitch Coluzzi Jennifer Lambert Signed
154 2020-05-12 15:00 Anonymous (not verified) 97.125.253.184 Rundle Creations Limited Liability Company 5816 Urbandale Avenue, Des Moines, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-12 Mark Lavern Rundle II rundlecreations@gmail.com Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith Signed (1) The employer does not elect the employers’ liability coverage. Erika Anne Rundle rundlecreations@gmail.com Co-Owner Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith Signed
2096 2024-03-14 14:53 Anonymous (not verified) 94.188.205.168 Scott Allen Proprietorship 2603 Bryant Blvd SW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-14 Scott Michael Allen allen.scottm@gmail.com Cedar Rapids Linn Iowa Daniel Bryant Bliek Jennifer Lee Allen Signed (1) The employer does not elect the employers’ liability coverage. Scott Michael Allen allen.scottm@gmail.com Self Cedar Rapids Linn Iowa Daniel Bryant Bliek Jennifer Lee Allen Signed
811 2021-12-22 17:31 Anonymous (not verified) 166.181.85.89 Demmer Construction Proprietorship 203 Michigan Ave Farley, IA 52046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-22 Charles Demmer charliedemmer@gmail.com Farley Dubuque Ia Michele Demmer Jennifer White Signed (1) The employer does not elect the employers’ liability coverage. Charles Demmer charliedemmer@gmail.com Self Farley Dubuque Ia Michele Kay Demmer Jennifer Marie White Signed
812 2021-12-22 17:31 Anonymous (not verified) 166.181.85.89 Demmer Construction Proprietorship 203 Michigan Ave Farley, IA 52046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-22 Charles Demmer charliedemmer@gmail.com Farley Dubuque Ia Michele Demmer Jennifer White Signed (1) The employer does not elect the employers’ liability coverage. Charles Demmer charliedemmer@gmail.com Self Farley Dubuque Ia Michele Kay Demmer Jennifer Marie White Signed
631 2021-09-02 22:46 Anonymous (not verified) 173.23.144.4 Lopez Framing LLC Limited Liability Company 566 walker st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-02 Diana A Garcia Lopez lopezframing0702@gmail.com Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed (1) The employer does not elect the employers’ liability coverage. Diana A Garcia Lopez lopezframing0702@gmail.com Owner Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed
2114 2024-03-25 18:18 Anonymous (not verified) 94.188.207.227 Lisa V Blessington Proprietorship 411 S 10th 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. 2024-03-25 Lisa Varie Blessington lblessington@yahoo.com Sac City Sac IA Jean Rexroat Jennifer Tovar Signed (1) The employer does not elect the employers’ liability coverage. Lisa Varie Blessington lblessington@yahoo.com Same Sac City Sac IA Jean Rexroat Jennifer Tovar Signed
913 2022-02-14 18:50 Anonymous (not verified) 72.25.23.147 Teimer Trucking Limited Liability Company 3277 102nd St. Durant, IA 52747 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-14 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Cedar Iowa Barry Boll Jennifer Treimer Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Owner Tipton Cedar Iowa Barry Boll Jennifer Treimer Signed
1976 2024-01-04 15:48 Anonymous (not verified) 94.188.207.224 Brawdy Services Proprietorship 7029 Prairie 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. 2024-01-01 Victor Brawdy heather.l.brawdy@gmail.com Urbandale Polk IA Summer Munoz Jennifer Wolters Signed (1) The employer does not elect the employers’ liability coverage. Victor Brawdy vb69ia@gmail.com Self Urbandale Polk IA Summer Munox Jennifer Wolters Signed
342 2020-12-28 10:19 Anonymous (not verified) 173.31.147.225 SAUL GUEVARA MEZA Proprietorship 26 WESTVIEW DRIVE APARTMENT 5 MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-22 SAUL GUEVARA MEZA ESMEJ2513@GMAIL.COM MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. SAUL GUEVARA MEZA ESMEJ2513@GMAIL.COM SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed
1309 2022-09-15 09:58 Anonymous (not verified) 96.31.1.206 PATTONS POWDER COATING Limited Liability Company 421 W MAPLE DRIVE HARTLEY IA 51346 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-15 DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. PATTONS POWDER COATING - DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM SELF HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed
168 2020-05-28 11:29 Anonymous (not verified) 173.31.147.225 RECYCLED SPIRITS LLC Limited Liability Company 43 ANN STREET MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-28 LACEY LAAKE BLAMB@SPENCERSCHOOLS.ORG MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. LACEY LAAKE BLAMB@SPENCERSCHOOLS.ORG SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
169 2020-05-28 11:31 Anonymous (not verified) 173.31.147.225 RECYCLED SPIRITS LLC Limited Liability Company 43 ANN ST MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-28 BETH LAMB BLAMB@SPENCERSCHOOLS.ORG MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. BETH LAMB BLAMB@SPENCERSCHOOLS.ORG SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
344 2020-12-28 11:31 Anonymous (not verified) 173.31.147.225 JEFFREY GOETZINGER Proprietorship 2112 ITHACA AVE SPIRIT LAKE IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-22 JEFFREY GOETZINGER WALKERINSURANCE@MCHSI.COM SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JEFFREY GOETZINGER WALKERINSURANCE@MCHSI.COM SELF SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
409 2021-02-18 16:35 Anonymous (not verified) 173.31.147.225 MATTHEW MYHRE DBA GUNS GALORE Proprietorship 2329 220TH AVE MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-18 MATTHEW MYHRE MYHRE3063@GMAIL.COM MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MATTHEW MYHRE DBA GUNS GALORE MYHRE3063@GMAIL.COM SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
600 2021-08-12 11:04 Anonymous (not verified) 173.19.179.111 ELIJAH HIX Proprietorship PO BOX 465 MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-11 ELIJAH HIX HIXSKIDOO800@GMAIL.COM MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ELIJAH HIX HIXSKIDOO800@GMAIL.COM SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
636 2021-09-10 14:56 Anonymous (not verified) 173.19.179.111 SHANNON SUNDINE Proprietorship 513 16TH ST SPIRIT LAKE IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 SHANNON SUNDINE SPSUNDINE@GMAIL.COM SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed (1) The employer does not elect the employers’ liability coverage. SHANNON SUNDINE SPSUNDINE@GMAIL.COM SELF SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
749 2021-11-15 16:05 Anonymous (not verified) 173.31.148.43 CHAMONE SWITZER Proprietorship PO BOX 72 FOSTORIA IA 51340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-15 CHAMONE SWITZER CHAMONE.SWITZER@GMAIL.COM FOSTORIA DICKINSON IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed (1) The employer does not elect the employers’ liability coverage. CHAMONE SWITZER CHAMONE.SWITZER@GMAIL.COM SELF FOSTORIA IA United States TAMI KILEIN JENNIFER YOUNGWIRTH Signed
790 2021-12-14 10:59 Anonymous (not verified) 173.31.148.43 SILVER LAKE ACCOUNTING LLC Limited Liability Company 178 W BAY RD I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-13 DARYA GAY DGAY@SILVERLAKEACCOUNTING.CPA LAKE PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. DARYA GAY DGAY@SILVERLAKEACCOUNTING.CPA SELF LAKE PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
792 2021-12-14 13:18 Anonymous (not verified) 173.31.148.43 BLUE WAVE SETTLEMENT LLC Limited Liability Company 1205 H AVENUE MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-14 SHANNON NORTON NOERTONSHANNON@YAHOO.COM MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. BLUE WAVE SETTLEMENT LLC NORTONSHANNON@YAHOO.COM SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
1382 2022-12-07 14:40 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC Limited Liability Company PO BOX 317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 AARON JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. AARON JONES STAYBOJI@GMAIL.COM SELF ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
1383 2022-12-07 14:42 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC Limited Liability Company PO BOX 317 ARNOLDS PARK IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM SELF ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
1717 2023-06-29 11:42 Anonymous (not verified) 94.188.205.169 POWDER COATING CENTER Limited Liability Company 61 3RD ST NE HARTLEY IA 51346 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-28 MATT EMBREY MSEMBREY21@GMAIL.COM HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MATT EMBREY MSEMBREY21@GMAIL.COM OWNER HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
1856 2023-09-29 13:18 Anonymous (not verified) 94.188.205.166 MUESSIGMANN ENTERTAINMENT LLC Limited Liability Company 906 2ND AVE SE SPENCER IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-27 JON MUESSIGMANN MUESSIGMANNENT@GMAIL.COM SPENCER CLAY Iowa TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JON MUESSIGMANN MUESSIGMANNENT@GMAIL.COM SELF SPENCER CLAY Iowa TAMI KLEIN JENNIFER YOUNGWIRTH Signed
48 2020-01-29 13:52 Anonymous (not verified) 97.64.170.98 DARIN J. KESSLER Proprietorship 1236 25TH ST AMES, IA 50010 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-29 DARIN J. KESSLER darinjkessler@gmail.com AMES STORY IOWA HEATHER DIANNE LANNING JENNY ANN ARENDS Signed (1) The employer does not elect the employers’ liability coverage. DARIN J. KESSLER darinjkessler@gmail.com SELF AMES STORY IOWA HEATHER DIANNE LANNING JENNY ANN ARENDS Signed
322 2020-11-17 14:06 Anonymous (not verified) 208.126.118.26 Wada Farms Limited Liability Company 2428 270th st Grand Mound, IA 52751 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-17 Wade Smith wade.smith1110@gmail.com Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed (1) The employer does not elect the employers’ liability coverage. Wada Farms wade.smith1110@gmail.com self Grand Mound clinton Iowa Megan Fuglsang Jenny Gordon Signed
649 2021-09-21 13:15 Anonymous (not verified) 208.126.118.26 Wade Smith DBA WADA Farms Proprietorship 2428 270th st, Grand Mound, IA 52751 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-09-21 Wade Smith wade.smith1110@gmail.com Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Wade Smith wade.smith1110@gmail.com self Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed
685 2021-10-20 14:14 Anonymous (not verified) 65.144.174.26 william c sawhill Proprietorship 1625 Delaware Ave, Des Moines, 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-20 William C Sawhill workorders@shoproyalflooring.com Des Moines Polk Iowa Nicholas W Sawhill Jenny M Steben Signed (1) The employer does not elect the employers’ liability coverage. William C Sawhill workorders@shoproyalflooring.com Self Des Moines Polk Iowa Nicholas W Sawhill Jenny M Steben Signed
184 2020-06-12 10:38 Anonymous (not verified) 174.243.112.246 brian kass Proprietorship 15064 kass road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-11 brian kass kass5kass@hotmail.com dubuque Iowa Iowa kelly kass jenny McIntyre Signed (1) The employer does not elect the employers’ liability coverage. brian kass kass5kass@hotmail.com self dubuque Iowa iowa Kelly Kass Jenny McIntyre Signed
1138 2022-06-01 15:01 Anonymous (not verified) 173.18.233.175 Roy Rohwedder Proprietorship 296 24th Ave SW Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Roy h Rohwedder rohwedder.roy@yahoo.com Cedar Rapids linn iowa Cash Rohwedder Brian Ashlock Signed (1) The employer does not elect the employers’ liability coverage. Brian Ashlock brian@tricounty-iowa.com Genaral Manager Cedar Rapids Linn IOWA Branden Peters Jenny Vaske Signed
2146 2024-04-12 11:42 Anonymous (not verified) 94.188.207.226 Ken McGraw Proprietorship 162 Green St Center Point IA 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. 2024-04-12 Ken Mcgraw kenmcgraw1974@gmail.com Center Point Linn Iowa Jenny Vaske Bob Nissen Signed (1) The employer does not elect the employers’ liability coverage. Brian Ashlock brian@tricounty-iowa.com General Manager Cedar Rapids Linn Iowa Bob Nissen Jenny Vaske 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
1829 2023-09-06 16:21 Anonymous (not verified) 94.188.207.228 JC Electric, LLC Limited Liability Company 205 South Clinton St., Apt 4, Albia, IA 52531 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 John Coady jcelectric.john@gmail.com Albia IA United States Todd Ryan Jer McAnich Signed (1) The employer does not elect the employers’ liability coverage. John Coady jcelectric.john@gmail.com Self Albia Monroe IA Todd Ryan Jer McAnich Signed
730 2021-11-08 14:58 Anonymous (not verified) 97.64.139.42 JZ INC Limited Liability Company 2509 Ne 10th CT Grimes Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-08 James Zastrow Zastrow74@gmail.com Grimes Iowa United States Kevan Wiggins Jeremy Holmes Signed (1) The employer does not elect the employers’ liability coverage. James Zastrow zastrow74@gmail.com Self grimes polk iowa Kevan Wiggins Jeremy Holmes Signed
1728 2023-07-08 10:48 Anonymous (not verified) 94.188.207.230 Lima Charlie LLC Limited Liability Company 56066 257th 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. 2023-06-10 Larry Homan larry@Lima-Charlie.biz Glenwood Iowa United States Erin Jenkins Jeremy Jenkins Signed (1) The employer does not elect the employers’ liability coverage. Larry Lee Homan Larry@Lima-Charlie.biz Owner Glenwood Iowa United States Erin Homan Jeremy Jenkins Signed
147 2020-05-02 09:07 Anonymous (not verified) 75.162.65.142 Tim Soy Proprietorship 3506 Amherst 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. 2020-05-01 Timothy Soy kingsoyboy@hotmail.com Des Moines Polk Iowa Aaron Page Jeremy Lukehart Signed (1) The employer does not elect the employers’ liability coverage. Timothy Soy kingsoyboy@hotmail.com Self Des Moines Polk Iowa Aaron page Jeremy Lukehart Signed
1312 2022-09-17 15:29 Anonymous (not verified) 97.125.242.121 Heartland Blinds Limited Liability Company 1255 Emmons St, Hiawatha, IA 52233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-17 Phil Murray proinstallia@yahoo.com Hiawatha Linn IA Jared Metcalf-Murray Jeremy Murray Signed (1) The employer does not elect the employers’ liability coverage. Christene Murray chrissymurray57@yahoo.com Self Hiawatha Linn IA Jared Metcalf-Murray Jeremy Murray Signed
1318 2022-09-22 11:18 Anonymous (not verified) 50.82.91.213 J. Thompson Builders, LLC Limited Liability Company 5291 Stoney Creek Ct. Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-22 Christopher Jacob Von Arx cjvonarx@hotmail.com Van Wert IA Decatur IA Iowa Christina Viehauser Jeremy Thompson Signed (1) The employer does not elect the employers’ liability coverage. Christina Viehauser christina@jthompsonbuilders.com Office Help Johnston Ia Polk IA Chris Von Arx Jeremy Thompson Signed
1319 2022-09-22 11:31 Anonymous (not verified) 50.82.91.213 J. Thompson Builders, LLC Limited Liability Company 5291 Stoney Creek Ct. Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-22 Mark Grant mjgrant1957@gmail.com Adel Dallas IA Christina Viehauser Jeremy Thompson Signed (1) The employer does not elect the employers’ liability coverage. Christina Viehauser christina@jthompsonbuilders.com Office Help Johnston Ia Polk IA Chris Von Arx Jeremy Thompson Signed
1537 2023-03-27 13:21 Anonymous (not verified) 94.188.207.228 miller hybrids Limited Liability Company 1213 Larch Ave, 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. 2022-01-01 Jeremy Wakerhauser jwakerhauser@gmail.com Sun Prairie WI United States Jeremy Wakerhauser Jeremy Wakerhauser Signed (1) The employer does not elect the employers’ liability coverage. Jeremy Wakerhauser jwakerhauser@gmail.com sole proprieter Sun Prairie WI United States Jeremy Wakerhauser Jeremy Wakerhauser 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
1311 2022-09-15 16:49 Anonymous (not verified) 174.235.213.195 JJ Jones contracting Limited Liability Company 2413 Valley High 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. 2022-09-15 Justin Jones jjjonescontractingllc@gmail.com Cedar Falls Black Hawk IA Dahoni Jones Jerold Cemrick Jones Signed (1) The employer does not elect the employers’ liability coverage. Justin Jones jjjonescontractingll@gmail.com Self Cedar Falls Black Hawk IA Dahoni Jones Jerold Cemrick Jones Signed
1353 2022-10-31 21:35 Anonymous (not verified) 50.82.84.225 Jerry Bassett Proprietorship 108 NE 22 Cr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 Jerry Bassett JerryDebBassett@aol.com GRIMES IA United States Deb Bassett Jerry Bassett Signed (1) The employer does not elect the employers’ liability coverage. Jerry Bassett JerryDebBassett@aol.com Self Grimes Polk Iowa Deb Bassett Jerry Bassett Signed
1688 2023-06-13 09:29 Anonymous (not verified) 94.188.207.228 Ron Burbach Proprietorship 7760 commerce park Dubuque Iowa 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. 2023-06-13 Ronald V Burbach allgreenron@msn.com Dubuque Dubuqie Iowa Mia Burnach Jerry david Signed (1) The employer does not elect the employers’ liability coverage. Ronald V Burbach allgreenron@man.com Same Dubuque Dubuque Iowa Mia F Burbach Jerry David Signed
1952 2023-12-12 13:26 Anonymous (not verified) 94.188.205.167 Austin Albin Proprietorship 2263 Railroad Street, Jacksonville, IL 62650 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-23 Austin R Albin albinaustin12@gmail.com Jacksonville Morgan IL Wayne Albin Jerry Roth Signed (1) The employer does not elect the employers’ liability coverage. Austin R Albin albinaustin12@gmail.com Self Jacksonville Morgan IL Wayne Albin Jerry Roth Signed
1664 2023-05-25 13:18 Anonymous (not verified) 94.188.207.227 Jason Vreeman Proprietorship 5571 170th St sibley 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. 2023-05-25 Jason Vreeman jvreeman21@gmail.com Sibley Osceola IA Katie Vreeman Jerry vreeman Signed (1) The employer does not elect the employers’ liability coverage. Jason Vreeman jvreeman21@gmail.com Self Sibley Osceola IA Katie Vreeman Jerry vreeman Signed
2162 2024-04-18 19:25 Anonymous (not verified) 94.188.205.177 Escobar Enterprises, LLC Limited Liability Company 125 East Broad Street, 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. 2024-04-18 Jesse Escobar jesse@escobar-enterprises.com Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed (1) The employer does not elect the employers’ liability coverage. Jesse Escobar jesse@escobar-enterprises.com owner Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed
635 2021-09-10 13:41 Anonymous (not verified) 166.181.84.226 JZH Roofing Specialists LLC Limited Liability Company 2127 Swan Dr, Norwalk, Iowa. 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed (1) The employer does not elect the employers’ liability coverage. Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Single member Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed
1073 2022-04-27 08:44 Anonymous (not verified) 173.187.173.190 black squirrel siding llc Limited Liability Company 1512 North first ave apartment C203S Coralville, Iowa 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-27 Lawerance James Brockert ozzman52382007@yahoo.com Atalissa Muscatine Iowa Rob Bartosh Jesse Minor-Nidey Signed (1) The employer does not elect the employers’ liability coverage. Lawerance James Brockert ozzman523582007@yahoo.com self Atalissa Muscatine Iowa Rob Bartosh Jesse Minor-Nidey Signed
1028 2022-04-02 11:01 Anonymous (not verified) 174.198.64.100 Great-Dain Htg/Ac & Plumbing Proprietorship 1616 Maple Rd. Harlan, Iowa 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-02 Richard Nee great-dain@hotmail.com Harlan Shelby Iowa Doug Clark Jesse Nee Signed (1) The employer does not elect the employers’ liability coverage. Richard Nee great-dain@hotmail.com Self Harlan Shelby Iowa Doug Clark Jesse Nee Signed
1425 2023-01-18 15:20 Anonymous (not verified) 174.228.35.74 Great-Dain Htg/Ac & Plumbing Proprietorship 1616 Maple Rd Harlan, Iowa 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-18 Richard Presly Nee great-dain@hotmail.com Harlan Shelby IA Theresa Clark Jesse Nee Signed (1) The employer does not elect the employers’ liability coverage. Richard Presley Nee great-dain@hotmail.com Self Harlan Shelby IA Theresa Clark Jesse Nee Signed
996 2022-03-22 23:37 Anonymous (not verified) 173.27.235.109 patriot t services Proprietorship 205 park st carlisle , ia 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-22 TRAVIS KEENEY knytrav@aol.com carlisle warren iowa james Ren Jesse Parker Signed (1) The employer does not elect the employers’ liability coverage. Travis Keeney knytrav@aol.com myself carlisle warren iowa james ren jesse parker Signed
1393 2022-12-13 12:45 Anonymous (not verified) 50.82.133.22 Ponderosa Outdoor Limited Liability Partnership 104 Vista Dr Montezuma, Ia 50171 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-13 Daniel Deaver ponderosaoutdoor@gmail.com Altoona Polk Iowa Faith Deaver Jessi Perkins Signed (1) The employer does not elect the employers’ liability coverage. Daniel Deaver ponderosaoutdoor@gmail.com self Altoona Polk Iowa Faith Deaver Jessi Perkins Signed
1702 2023-06-22 22:57 Anonymous (not verified) 94.188.207.230 A&M Consulting LLC Limited Liability Company 1208 5th Ave, North Humboldt Iowa, 50548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-22 maureen Waweru maureenrealtyaz@yahoo.com chandler AZ United States John Waweru Jessica Bellinger Signed (1) The employer does not elect the employers’ liability coverage. maureen Waweru maureenrealtyaz@yahoo.com Self chandler AZ United States John Waweru Jessica Bellinger Signed
9 2019-12-16 11:33 Anonymous (not verified) 50.81.115.85 Travis Garrett and Caleb Elliott Partnership P.O. Box 55, Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-16 Travis Garrett onethird4599@gmail.com Boone Boone IA Katie Frame Jessica Carroll Signed (1) The employer does not elect the employers’ liability coverage. Travis Garrett & Caleb Elliott onethird4599@gmail.com Owner Boone Boone IA Katie Frame Jessica Carroll Signed
10 2019-12-16 11:35 Anonymous (not verified) 50.81.115.85 Travis Garrett and Caleb Elliott Partnership P.O. Box 55, Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-16 Caleb Elliott onethird4599@gmail.com Boone Boone IA Katie Frame Jessica Carroll Signed (1) The employer does not elect the employers’ liability coverage. Travis Garrett & Caleb Elliott onethird4599@gmail.com Owner Boone Boone IA Katie Frame Jessica Carroll Signed
1882 2023-10-27 10:40 Anonymous (not verified) 94.188.205.166 Ron's SIding and Construction Proprietorship 6097 26th 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. 2025-02-02 Ron Heggebo heggebojessica@yahoo.com Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed (1) The employer does not elect the employers’ liability coverage. Ronnie Heggebo heggebojessica@yahoo.com self Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed
1883 2023-10-27 10:49 Anonymous (not verified) 94.188.207.228 Ron's SIding and Construction Proprietorship 6097 26th 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. 2023-10-27 Ron Heggebo heggebojessica@yahoo.com Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed (1) The employer does not elect the employers’ liability coverage. Ron Heggebo heggebojessica@yahoo.com Self Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed
1416 2023-01-09 13:05 Anonymous (not verified) 67.55.184.55 Austin Lanz Proprietorship 3015 M 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. 2023-01-09 Austin Robert Lanz austinlanz52@gmail.com Moring Sun Iowa IA Robert Lowell Lanz Jessica Leann Ewart Signed (1) The employer does not elect the employers’ liability coverage. Austin Robert Lanz austinlanz52@gmail.com Self Moring Sun Iowa IA Robert Lowell Lanz Jessica Leann Lanz Signed
1307 2022-09-14 13:40 Anonymous (not verified) 216.51.227.123 elite business ckeaning Proprietorship 1350 kennel ct unit c2 north liberty IA 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-14 rogelio morales ortega info@elitebusinesscleaning.com iowa city johnson iowa cesar morales ortega alma rosa perez Signed (1) The employer does not elect the employers’ liability coverage. elite busibess cleaning info@elitebusinesscleaning.com president north liberty johnson iowa karina aguilar jessica lee Signed
487 2021-04-20 11:10 Anonymous (not verified) 207.191.193.167 Chento Construction Proprietorship 702 Lincoln St. Ainsworth, IA 52201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-05 Alberto Garcia chentoconstruction@hotmail.com Ainsworth Washington Iowa Anthony Johnson Jessica Lopez Signed (1) The employer does not elect the employers’ liability coverage. Alberto Garcia chentoconstruction@hotmail.com Owner Ainsworth Washington Iowa Anthony Johnson Jessica Lopez 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
1870 2023-10-17 16:13 Anonymous (not verified) 94.188.205.176 Diamond ridge Proprietorship 1842 Glenwood cir Des Moines Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-17 Marianna Landeros cheri6876@yahoo.com Des moines Polk Iowa Marianna Landeros Cheri Martinez Signed (1) The employer does not elect the employers’ liability coverage. Marianna Landeros landerosmary@gmail.com Self Des Moines Polk Iowa Cheri Martinez Jessica Newton Signed
71 2020-02-21 05:24 Anonymous (not verified) 70.100.107.197 CRS Inc. Proprietorship 1442 3rd Ave SW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-20 Monica Christensen monicalchristensen@gmail.com Belmond Wright Iowa Jessica Tempus Dawn Butler Signed (1) The employer does not elect the employers’ liability coverage. Monica Christensen monicalchristensen@gmail.com Consultant Belmond Iowa United States Dawn Butler Jessica Tempus Signed
368 2021-01-21 15:12 Anonymous (not verified) 97.125.235.64 R. A. Snow Removals, Inc Proprietorship 525 7th St NW, Altoona, IA 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-21 Robert Aaron Snow rasnowremovals.inc@gmail.com Altoona Polk Iowa Shannon Keely Moses Jessy James Dentler Signed (1) The employer does not elect the employers’ liability coverage. Robert Aaron Snow rasnowremovals.inc@gmail.com President Altoona IA United States Shannon Keely Moses Jessy James Dentler Signed
681 2021-10-19 15:44 Anonymous (not verified) 65.144.174.26 Humberto Albino Proprietorship 3914 Aurora Ave Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-19 Humberto Albino albinohumberto73@gmail.com Des Moines Polk Iowa Miguel Albino Jesus Albino Signed (1) The employer does not elect the employers’ liability coverage. Humberto Albino albinohumberto73@gmail.com Owner Des Moines Polk Iowa Miguel Albino Jesus Albino Signed
245 2020-08-25 15:20 Anonymous (not verified) 107.77.207.111 J&R cleaning co LLC Limited Liability Company 14300 Holcomb ave #210 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. 2020-08-25 José A salas romero chinito80sr@hotmail.com Desmoines Polk Iowa Ana López Jesus gonzales Signed (1) The employer does not elect the employers’ liability coverage. José romero chinito80sr@hotmail.com Owner Desmoines Polk Iowa Ana lopez Jesus Gonzales Signed
986 2022-03-18 16:46 Anonymous (not verified) 174.213.145.90 Gonzalez Contractors LLC. Limited Liability Company 150 NE 41st St Unit 109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Elmer Gonzalez gonzalez922014@icloud.com Ankeny Polk IA Kassandra Gonzalez Jesus Gonaalez Signed (1) The employer does not elect the employers’ liability coverage. Elmer Gonzalez gonzalez922014@icloud.com Owner Ankeny Polk IA Kassandra Gonzalez Jesus Gonzalez Signed
1002 2022-03-23 13:04 Anonymous (not verified) 174.255.6.78 Gonzalez Contractors LLC. Limited Liability Company 240 NE 41st St unit 203 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Elmer Gonzalez gonzalez922014@icloud.com Ankeny Polk IA Kassandra Gonzalez Jesus Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Elmer Gonzalez gonzalez922014@icloud.com Owner Ankeny Polk IA Kassandra Gonzalez Jesus Gonzalez Signed
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
1104 2022-05-16 13:00 Anonymous (not verified) 65.144.174.26 Medrano Flooring LLC Limited Liability Company 8186 Harbach Blvd Apt 1, 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. 2022-05-16 Joel Medrano medranojoel397@gmail.com Clive Polk Iowa Ana Leon Jesus Maldonado Signed (1) The employer does not elect the employers’ liability coverage. Joel Medrano medranojoel397@gmail.com Self Clive Polk Iowa Ana Leon Jesus Maldonado Signed
1991 2024-01-17 00:34 Anonymous (not verified) 94.188.207.223 Wasabi urbandale llc Limited Liability Company 7115 Ridgedale ct, Johnston,IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-17 Wenhui chen michaelchen@wasabidsm.com Johnston Polk Iowa Yilian lin Ji jie jie Signed (1) The employer does not elect the employers’ liability coverage. Wenhui chen michaelchen@wasabidsm.com Owner Johnston Polk Iowa Yilian lin Ji jie jie Signed
163 2020-05-20 11:58 Anonymous (not verified) 173.27.1.111 David Proprietorship 4023 E 28th st 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-20 David Ortiz jdiconstrucction@gmail.com Des Moines Polk County Iowa Erika Olague Jieldh Ortiz-Olague Signed (1) The employer does not elect the employers’ liability coverage. David Ortiz jdiconstrucction@gmail.com JDI Construction Des Moines Polk County Iowa Erika Olague Jieldh Ortiz-Olague Signed
1037 2022-04-07 08:16 Anonymous (not verified) 104.207.27.18 SION LUTHERAN CHURCH Proprietorship 4525 FINCH AVE LAKE MILLS, IA 50450 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-07 JANE BRUNSVOLD janebrunsvold@yahoo.com LAKE MILLS WINNEBAGO IOWA ANDREW STENSRUD JILL FLUGUM Signed (1) The employer does not elect the employers’ liability coverage. ANDREW STENSRUD ANDREW@STENSRUDINSURANCE.COM INSURANCE AGENT LAKE MILLS WINNEBAGO IOWA JANE BRUNSVOLD JILL FLUGUM Signed
336 2020-12-11 11:55 Anonymous (not verified) 173.16.197.72 A Metro Snow Removal And Lawn Care Limited Liability Company 6436 Washington Ave Windsor Heights, Iowa 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-11 Jeff Lamp Sr. jeff.lamp79@gmail.com Windsor Height Polk Iowa Rick Brown Jill Fresh Signed (1) The employer does not elect the employers’ liability coverage. Jeff Lamp Sr. Jeff.lamp79@gmail.com Owner Windsor Heights Polk Iowa Rick Brown Jill Fresh Signed
1855 2023-09-27 12:56 Anonymous (not verified) 94.188.207.224 Lincoln Hotel Group Limited Liability Company 9240 Andermatt Drive Suite 1 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-27 John Edward Klimpel jklimpel@lincolnhotelgroup.com Lincoln Lancaster NE Carrie A. Fleck Jill N. Korta Signed (1) The employer does not elect the employers’ liability coverage. Brent Besch brent.besch@marshmma.com Client Lincoln Nebraska NE Carrie A Fleck Jill N Korta Signed
278 2020-10-09 11:25 Anonymous (not verified) 174.243.82.229 ServTwelve7 Consulting, LLC Limited Liability Company 1903 Elmhurst Avenue Humboldt, IA 50548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-09 Sonya Satern Sonya.satern@ServTwelve7.com Humboldt Humboldt Iowa Cindy Vik Jill Westre Signed (1) The employer does not elect the employers’ liability coverage. Sonya Satern Sonya.Satern@ServTwelve7.com self Humboldt Humboldt Iowa Cindy Vik Jill Westre Signed
1953 2023-12-12 15:38 Anonymous (not verified) 94.188.207.226 Ryan Gideon Proprietorship 9320 Elmcrest Dr 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. 2023-12-12 Ryan Gideon rgid8403@gmail.com Norwalk Warren IA Jim Lane Jim Lane Signed (1) The employer does not elect the employers’ liability coverage. Ryan Gideon rgid8403@gmail.com Owner Norwalk Warren IA jim Lane Jim Lane Signed