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:
818	2022-01-02 11:34	Anonymous (not verified)	184.94.130.66	dylan nelson trucking llc	Limited Liability Company	2011 465th street hanley falls mn 56245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-02	dylan nelson	dylancvi@gmail.com	hanley falls mn	yellow medicine	mn	derek verhelst	mike fales	Signed	(1) The employer does not elect the employers’ liability coverage.	dylan nelson	dylancvi@gmail.com	owner	hanley falls mn	yellow medicine	mn	derek verhelst	mike fales	Signed
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
1143	2022-06-06 15:48	Anonymous (not verified)	63.152.93.184	Adaptability Plus	Limited Liability Company	904 W 4th 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.	2022-01-02	Timothy Combs	tcombshd@gmail.com	Cedar Falls	Iowa	United States	Mark Moser	Teresa Tjaden	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Combs	tcombshd@gmail.com	none	Cedar Falls	Black Hawk	Iowa	Mark Moser	Teresa Tjaden	Signed
1144	2022-06-06 15:51	Anonymous (not verified)	63.152.93.184	Mark Moser	Limited Liability Company	904 W 4th St., Waterloo Iowa 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-02	Mark Moser	mpmmoser@gmail.com	Waterloo	Black Hawk	Iowa	Timothy Combs	Teresa Tjaden	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Moser	mpmmoser@gmail.com	none	Waterloo	Black Hawk	Iowa	Timothy Combs	Teresa Tjaden	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
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
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
883	2022-02-02 14:07	Anonymous (not verified)	104.201.67.178	Juan Monterde	Proprietorship	9235 Swanson 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.	2022-01-01	Juan Monterded	s.thomas@nationwideofficecare.com	Cedar Rapids	Linn	Iowa	Cory Shelton	Scott D Thomas	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott D Thomas	scottthomascpa@msn.com	Consultant	West Des Moines	IA	United States	Rich Darr	Mari Lopez	Signed
884	2022-02-02 14:10	Anonymous (not verified)	104.201.67.178	Magdalena Lopez Raymundp	Proprietorship	2820Pennsylvania Ave, 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.	2022-01-01	Magdalena Lopez Raymundo	scottthomascpa@msn.com	Dubuque	Dubuque	Iowa	Rich Darr	Mari Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott D Thomas	scottthomascpa@msn.com	Consultant	West Des Moines	IA	United States	Rich Darr	Mari Lopez	Signed
885	2022-02-02 14:13	Anonymous (not verified)	104.201.67.178	Maria DeLeon	Proprietorship	2805 10th Avenue North, 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.	2022-01-01	Maria DeLeon	scottthomascpa@msn.com	Fort Dodge	Webster	Iowa	Rich Darr	Mari Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott D Thomas	s.thomas@nationwideofficecare.com	Consultant	West Des Moines	IA	United States	Rich Darr	Mari Lopez	Signed
1005	2022-03-24 14:34	Anonymous (not verified)	165.225.57.246	Beardmore Construction	Limited Liability Company	404 E 1st Ave 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.	2022-01-01	Nathan Fosenburg	nfosenburg@yahoo.com	Indianola	Warren	IA	Kerri Fosenburg	Nathan Fosenburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Fosenburg	nfosenburg@yahoo.com	owner	Indianola	Warren	IA	Kerri Fosenburg	Nathan Fosenburg	Signed
1408	2023-01-04 16:12	Anonymous (not verified)	50.82.188.217	Guerrero Masonry	Proprietorship	5003 Keystone Rdg 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.	2022-01-01	Jaime Guerrero	jaime.guerrero@mchsi.com	Cedar Rapids	IA	United States	Susan Bender	Larry Bender	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaime Guerrero	jaime.guerrero@mchsi.com	self	CEDAR RAPIDS	Linn	Iowa	Susan Bender	Larry Bender	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
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
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
817	2021-12-30 12:58	Anonymous (not verified)	50.80.80.37	Leaf Filter	Limited Liability Company	1595 Georgetown Road 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.	2021-12-30	Kenneth Van Hook	kennyvanhook1976@gmail.com	Port Byron	Rock Island	IL	Sharon Van Hook	Judy Hoffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	cdunbar@leaffilter.com	Manager	Bettendorf	Scott County	IA	Cody Dunbar	Jordan Nisiewicz	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
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
341	2020-12-23 08:52	Anonymous (not verified)	174.243.82.219	Jason D Struchen	Proprietorship	1778 210th St Webster City, IA 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-23	Jason David Struchen	steruchen75@gmail.com	Webster City	Hamilton	Iowa	NA	NA	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason D Struchen	struchen75@gmail.com	Same	Webster City	Hamilton	Iowa	NA	NA	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
810	2021-12-22 15:13	Anonymous (not verified)	167.142.30.134	Bouillon Lawn Care	Proprietorship	3074 Lodge 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.	2021-12-22	Jerry Bouillon	greeneflowerman@yahoo.com	Greene	Floyd	Iowa	Lucas Wedeking	Misty Osborn	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Bouillon	Greeneflowerman@yahoo.com	Self	Greene	Floyd	Iowa	Lucas Wedeking	Misty Osborn	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
809	2021-12-21 14:42	Anonymous (not verified)	75.162.173.166	Mike Money	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.	2021-12-21	Michael David Money	poojennings78@gmail.com	Des Moines	Polk	Iowa	Diana Jennings	Steve Jennings	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael David Money	poojennings78@gmail.com	self	Des Moines	Polk	Iowa	Diana Jennings	Steve Jennings	Signed
806	2021-12-20 08:56	Anonymous (not verified)	50.124.217.66	Lyndon L Giese dba G&G Farms Trucking	Proprietorship	402 St Olaf Ave S 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.	2021-12-20	Lyndon L Giese	ldgiese@frontiernet.net	Canby	Yellow Medicine	Minnesota	Jeff Sinn	Tiffany Gohr	Signed	(1) The employer does not elect the employers’ liability coverage.	Lyndon L Giese	ldgiese@frontiernet.net	Owner	Canby	Yellow Medicine	Minnesota	Jeff Sinn	Tiffany Gohr	Signed
807	2021-12-20 09:30	Anonymous (not verified)	63.153.145.38	Jerry Ollerich Trucking	Proprietorship	46884 267th Street Sioux Falls SD 57106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Jerald William Ollerich	jeanollerich@yahoo.com	Sioux Falls	Minnehaha	SD	James K. Ollerich	Joanne K. Berg	Signed	(1) The employer does not elect the employers’ liability coverage.	Jean Staebell Ollerich	jeanollerich@yahoo.com	Wife/manager	Sioux Falls	Minnehaha	SD	James K. Ollerich	Joanne K. Berg	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
805	2021-12-20 08:40	Anonymous (not verified)	65.144.174.26	TILE DECOR INC	Proprietorship	1702 WEST 3RD 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.	2021-12-17	HUGO COJON	CAMEYHUGO@GMAIL.COM	PERRY	DALLAS	IOWA	GABRIELA PEREZ	NARCISO HIDALGO	Signed	(1) The employer does not elect the employers’ liability coverage.	HUGO COJON	CAMEYHUGO@GMAIL.COM	OWNER	PERRY	DALLAS	IOWA	GABRIELA PEREZ	NARCISO HIDALGO	Signed
801	2021-12-16 21:35	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson st new Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
802	2021-12-16 21:44	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson St New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Jeffrey Allen Webster	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
803	2021-12-16 21:47	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson St New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Ethan Willett	kustomhomeimprovements.dk@gmail.com	Osceola	Clarke	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
804	2021-12-16 21:51	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson st New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Curtis Allen Masterson	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
795	2021-12-15 07:47	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Douglas James Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	IA	IA	John Kenneth Lampe	Kenneth Roman Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	Cedar Rapids	Linn	Iowa	John Kenneth Lampe	Kenneth Roman Lampe	Signed
796	2021-12-15 07:58	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	John Kenneth Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	Kenneth Roman Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	IA	Linn	Douglas James Lampe	Kenneth Roman Lampe	Signed
797	2021-12-15 08:01	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Kenneth Roman Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	John Kenneth Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	Linn	Iowa	Douglas James Lampe	John Kenneth Lampe	Signed
798	2021-12-15 08:03	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Jared J Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	John Kenneth Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	Linn	Iowa	Douglas James Lampe	John Kenneth Lampe	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
788	2021-12-14 09:36	Anonymous (not verified)	162.250.36.34	Sylvester Enterprises, LLC	Limited Liability Company	4800 Sylvester Rd. Webb, Ia. 51366	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Tim Christian Sylvester	isusly89@gmail.com	Webb	Clay	Iowa	Dennis Dwain Somers	LInda Elayne Somers	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Christian Sylvester	slyenterprisesllc20@gmail.com	Owner	Webb	Clay	Iowa	Dennis Dwain Somers	Linda Elayne Somers	Signed
789	2021-12-14 09:39	Anonymous (not verified)	162.250.36.34	Sylvester Enterprises, LLC	Limited Liability Company	4800 Sylvester Rd. Webb, Iowa 51366	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Christian Grant Sylvester	slyfarms97@gmail.com	Webb	Clay	iowa	Dennis Dwain Somers	LInda Elayne Somers	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Christian Sylvester	slyenterprisesllc20@gmail.com	Owner	Webb	Clay	Iowa	Dennis Dwain Somers	Linda Elayne Somers	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
794	2021-12-14 14:18	Anonymous (not verified)	65.144.174.26	iDesign	Limited Liability Company	805 15th 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.	2021-12-14	Michelle Wiedman	idesigninside@gmail.com	Dallas Center	Dallas	IA	Carl Sprague	Neal Bunn	Signed	(1) The employer does not elect the employers’ liability coverage.	Michelle Wiedman	idesigninside@gmail.com	Self	Dallas Center	Dallas	Iowa	Carl Sprague	Neal Bunn	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
793	2021-12-14 14:16	Anonymous (not verified)	174.22.96.99	Dubuque County Energy District	Limited Liability Company	700 Locust Street, #195	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-10	Michaela Marie Freiburger	michaela@energydistrict.org	Dubuque	Dubuque	IA	Diane Freiburger, Mother	Michael Freiburger, Father	Signed	(1) The employer does not elect the employers’ liability coverage.	Michaela Marie Freiburger	michaela@energydistrict.org	Contracted Vendor for the Dubuque County Energy District	Dubuque	Dubuque	IA	Diane Freiburger	Michael Freiburger	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
786	2021-12-09 15:37	Anonymous (not verified)	216.51.251.31	3F Express, LLC	Limited Liability Company	920 32nd Ave West Po Box 1117 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.	2021-12-09	Tess Jackson	accounting@3fexpressllc.com	Milford	Dickinson	Iowa	Amanda Wolff	Mandy Kabrick	Signed	(1) The employer does not elect the employers’ liability coverage.	Tess Jackson	accounting@3fexpressllc.com	Owner	Milford	Dickinson	IA	Amanda Wolff	Mandy Kabrick	Signed
782	2021-12-08 10:11	Anonymous (not verified)	173.21.158.248	Barry Duncan	Proprietorship	2020 S.E. Four Seasons 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.	2021-12-08	BARRY DUNCAN	bduncan1452@gmail.com	Ankeny	IA	Iowa	Kathy Belieu	Summer Belieu-Slemp	Signed	(1) The employer does not elect the employers’ liability coverage.	BARRY DUNCAN	bduncan1452@gmail.com	Self	Ankeny	Polk	Iowa	Kathy Belieu	Summer Belieu-Slemp	Signed
783	2021-12-08 10:25	Anonymous (not verified)	173.31.148.43	Nick Larsen	Proprietorship	1305 7th 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.	2021-12-08	Nick Larsen	larsennick77@gmail.com	Milford	Dickinson	IA	JOSEPH THOMAS LORING	Kristine Ann Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	Nick Larsen	joel@walkerinsuranceia.com	Self	Milford	Dickinson	IA	JOSEPH THOMAS LORING	Kristine Ann Walker	Signed
784	2021-12-09 09:03	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.	2021-12-08	James Scott Zastrow	Zastrow74@gmail.com	Grimes	IA	United States	NIcole Zastrow	Kevan Wiggins	Signed	(1) The employer does not elect the employers’ liability coverage.	James scott Zastrow	loffredon@aol.com	Self	Grimes	IA	United States	nicole zastrow	Kevan wiggins	Signed
779	2021-12-06 10:43	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue 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.	2021-12-06	Douglas A Munn	munnent1328@gmail.com	Clear lake	IA	IA	Troy Thomas Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Munn	Troy@munnentllc.com	Owner	Clear Lake	Cerro Gordo	Iowa	Troy Thomas Munn	Marjorie Marie Munn	Signed
780	2021-12-06 10:45	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue 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.	2021-12-06	Troy T Munn	Troy@munnentllc.con	Clear lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Thomas Munn	troy@munnentllc.com	Same	Clear Lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	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
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
777	2021-12-04 10:20	Anonymous (not verified)	107.77.161.58	Martinez Painting	Proprietorship	3219 bowdoin st desmoines ia 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-04	Martinez Manuel	Manuelitogladis29@gmail.com	Desmoines	Polk	Iowa	Yasco adilovic	Samir radinovick	Signed	(1) The employer does not elect the employers’ liability coverage.	Martinez Manuel	Manuelitogladis29@gmail.com	Owner	Desmoines	Polk	Iowa	Yasco adilovic	Samir radinovic	Signed
776	2021-12-03 10:26	Anonymous (not verified)	192.230.128.72	Richard Makohoniuk	Proprietorship	785 SE Walnut Ridge 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.	2021-12-03	Richard Makohoniuk	111@mchsi.com	Waukee	Dallas	Iowa	Tara Makohoniuk	Richard Makohoniuk	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Makohoniuk	111@mchsi.com	Self	Waukee	Dallas	IA	Tara Makohoniuk	Richard Makohoniuk	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
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
774	2021-11-29 12:28	Anonymous (not verified)	174.198.82.208	Demetrio's Construction	Proprietorship	2018 Heights Ave 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.	2021-11-29	Guillermo Demetrio	moralesdalia44@yahoo.com	Sioux City	Woodbury	Iowa	Dalia E. Morales Galvez	Vanessa Topete	Signed	(1) The employer does not elect the employers’ liability coverage.	Guillermo Demetrio	moralesdalia44@yahoo.com	Owner	Sioux City	Woodbury	Iowa	Dalia Morales Galvez	Vanessa Topete	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
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
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
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
764	2021-11-22 15:33	Anonymous (not verified)	198.14.219.227	Central Iowa Painting and Contracting LLC	Limited Liability Company	408 Freel Drive, Ste. 101, 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.	2021-11-22	Matthew Paul Klucas	mklucas50@gmail.com	Fort Dodge	Webster County	Iowa	Jordan Watkins	Scott Schuler	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Klucas	mklucas50@gmail.com	Owner of Buisness	Fort Dodge	Webster County	Iowa	Jordan Watkins	Scott Schuler	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
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
760	2021-11-21 16:31	Anonymous (not verified)	107.77.206.216	Jacob Odean	Limited Liability Company	6634 Lorton CT. Davenport IA 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.	2021-11-21	Jacob James Odean	jodean5725@gmail.com	DAVENPORT	IA	United States	James Odean	Vickie Odean	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob James Odean	jodean5725@gmail.com	Same	DAVENPORT	SCOTT	United States	James Odean	Vickie Odean	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
754	2021-11-19 08:27	Anonymous (not verified)	65.144.174.26	miguel albino	Proprietorship	8760 cody dr. unit 107 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.	2021-11-19	miguel albino	albino.miguel627@gmail.com	west des moines	united states	iowa	humbeto albino	johnothan albino	Signed	(1) The employer does not elect the employers’ liability coverage.	miguel albino	albino.miguel627@gmail.com	self	west des moines	united states	iowa	humberto albino	johnothan	Signed
755	2021-11-19 13:25	Anonymous (not verified)	65.144.174.26	Central Iowa Insulation and Floors Inc	Proprietorship	14858 118 Ave, 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.	2021-11-19	Ivan Pilat	centraliowaif@gmail.com	Indianola	Warren	Iowa	Mark Kapustin	Vladimir Orbinan	Signed	(1) The employer does not elect the employers’ liability coverage.	Ivan Pilat	centraliowaif@gmail.com	Self	Indianola	Warren	Iowa	Mark Kapustin	Vladimir Orbinan	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
757	2021-11-19 15:11	Anonymous (not verified)	184.80.177.137	Upper Room, LLC	Limited Liability Company	1314 9th St SE -Dyersville, 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.	2021-11-19	DeAnne M McCarraher	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville, IA	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
758	2021-11-19 15:12	Anonymous (not verified)	184.80.177.137	Upper Room, LLC	Limited Liability Company	1314 9th St SE - 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.	2021-11-19	Keith McCarraher	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
759	2021-11-19 18:54	Anonymous (not verified)	173.23.148.83	EFP Construction	Limited Liability Company	1825 East Grand Ave 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.	2021-11-19	Bobby Perry	efpconstruction21@gmail.com	Des Moines	Polk	Iowa	Tanya Perry	Megan McIlhon	Signed	(1) The employer does not elect the employers’ liability coverage.	Bobby Perry	efpconstruction21@gmail.com	Self	Des Moines	Polk	Iowa	Tanya Perry	Megan McIlhon	Signed
753	2021-11-17 22:09	Anonymous (not verified)	107.77.219.76	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.	2021-11-17	Nathan Nash Shaw	nathan@shawlivestock.com	Moravia	Monroe	Iowa	Scott Saveraid	Sandra Blindauer	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Nathan Shaw	nathan@shawlivestock.com	Self	Moravia	Monroe	Iowa	Scott Saveraid	Sandra Blindauer	Signed
750	2021-11-16 12:34	Anonymous (not verified)	172.58.83.130	Austin Carlson	Proprietorship	1341 iron city avenue atalissa 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.	2021-11-16	Austin Carlson	toppeakconstruction@gmail.com	Atalissa	Muscating	Iowa	Jordan Nisiewicz	Sam Apponey	Signed	(1) The employer does not elect the employers’ liability coverage.	Jorden Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Jackson	Missouri	Jordan Nisiewicz	Sam Apponey	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
748	2021-11-15 13:01	Anonymous (not verified)	174.243.83.168	NC contracting	Limited Liability Company	2212 Oakwood 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.	2021-11-15	Nicholas Cheney	444nicholas@gmail.com	Ames	Iowa	Iowa	Cassie Cheney	Shawn Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Cheney	444nicholas@gmail.com	Self	Ames	Story	Iowa	Cassie Cheney	Shawn Hay	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
762	2021-11-22 09:23	Anonymous (not verified)	71.34.169.117	Oscar Lopez	Proprietorship	1175 Office Park Road Apt 109 West Des Moines, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-15	Oscar Lopez	deb@piciowa.com	WDM	Polk	ia	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Oscar Lopez	deb@piciowa.com	self	WDM	Polk	IA	Debra Stratton	Kelly Denger	Signed
747	2021-11-12 15:08	Anonymous (not verified)	75.162.157.80	Unique Hardwood Floors, LLC	Limited Liability Company	1202 Army Post Rd. des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-12	Jose A Dominguez Lopez	uniquefloorsdmi@gmail.com	Des Moines	USA	Iowa	Elizabeth Dominguez	Liliana Sanchez Gutierrez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose A Dominguez Lopez	uniquefloorsdmi@gmail.com	Owner	Des Moines	USA	Iowa	Elizabeth Dominguez	Liliana Sanchez Gutierrez	Signed
746	2021-11-11 19:26	Anonymous (not verified)	166.181.87.101	Joshua Duncan	Proprietorship	2237 west high street Davenport Iowa 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.	2021-11-11	Joshua Duncan	Jduncan8669@gmail.com	Davenport	Scott	Iowa	Megan Ward	Joseph Duncan	Signed	(1) The employer does not elect the employers’ liability coverage.	Megan Ward	megward1986@gmail.com	Fiancé	Davenport	Scott	Iowa	Megan Ward	Joseph Duncan	Signed
731	2021-11-09 14:08	Anonymous (not verified)	166.181.87.107	Leaf Filter North	Limited Liability Company	3060 SE Grimes Blvd, STE 100 Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-09	Jordan Cunningham	jcunnsalvage@gmail.com	Baxter	Jasper	Iowa	Karen Cunningham	Makenzie Raridon	Signed	(1) The employer does not elect the employers’ liability coverage.	Megan McIlhon	mmcilhon@leaffilter.com	Office Manager	Grimes	Polk	Iowa	Karen Cunningham	Makenzie Raridon	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
733	2021-11-09 15:35	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	Dustin Kohler	dustink@unitedtradesgroup.org	Des Moines	Polk	Iowa	Ryan Drabek	Trevor Spidle	Signed	(1) The employer does not elect the employers’ liability coverage.	Tory Webb	torywebbdmi@gmail.com	Owner, Management	Norwalk	Warren	Iowa	Ryan Drabek	Trevor Spidle	Signed
787	2021-12-13 16:15	Anonymous (not verified)	64.5.77.84	Heartland Counseling Services	Limited Liability Company	813 Flindt 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.	2021-11-05	Kathleen Ruscitto	info@heartlandcounselingia.com	STORM LAKE	Iowa	United States	David Kirk	Michael Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Kathleen Ruscitto	info@heartlandcounselingia.com	Self/Owner	STORM LAKE	Iowa	United States	David Kirk	Michael Robertson	Signed
711	2021-11-04 13:07	Anonymous (not verified)	174.216.69.18	Corey Gramowski	Proprietorship	2101 21st ST Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-04	Corey Gramowski	gramowski@windstream.net	Emmetsburg	Palo Alto	IA	Frank Kliegl	John Heddinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Gramowski	gramowski@windstream.net	Self	Emmetsburg	Palo Alto	IA	Frank Kliegl	John Heddinger	Signed
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
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
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
702	2021-11-01 09:23	Anonymous (not verified)	173.28.195.56	Garcia Snow Removal	Limited Liability Company	213 E 7th Street, West Liberty, Iowa 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-01	Benji A Garcia	garciabenji23@gmail.com	West Liberty	IA	Norway	Luis Ordenana-Choez	Vicente Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Benji Garcia	garciabenji23@gmail.com	Member	West Liberty	Muscatine	Iowa	Luis Ordenana-Choez	Vicente Garcia	Signed
703	2021-11-01 11:25	Anonymous (not verified)	65.144.174.26	G & D Tile	Proprietorship	2210 E Rose Ave Apt 9 Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-01	Gerson Mejia	gersonmejia25@icloud.com	Des Moines	Polk	Iowa	Katherine Castillo	Jose Leonardo	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerson Mejia	gersonmejia25@icloud.com	Owner	Des Moines	Polk	Iowa	Katherine Castillo	Jose Leonardo	Signed
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
700	2021-10-29 11:04	Anonymous (not verified)	174.198.66.50	T&C Lawn Care LLC	Limited Liability Partnership	1827 Black Hawk St Waterloo IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Cody R Woodley	cody.woodley50@gmail.com	Cedar Falls	Blackhawk	Iowa	Tara R Woodley	Sara Woodley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristi S. Demuth Agency, Inc.	kdemuth@amfam.com	Client	Waverly	Bremer	Iowa	Cody R Woodley	Tyler M Croft	Signed
701	2021-10-29 18:35	Anonymous (not verified)	173.18.85.215	Saunders Construction	Proprietorship	7304 SW 14th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Charles Saunders	charlessaunders901@gmail.com	Des Moines	Iowa	Iowa	Ramona Mitchell	Rasheedah Gasaway	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Saunders	charlessaunders901@gmail.com	Owner	Des Moines	IA	United States	Ramona Mitchell	Rasheedah Gasaway	Signed
712	2021-11-05 10:38	Anonymous (not verified)	64.5.73.247	Glenn Langel	Proprietorship	20581 300th St, Templeton, IA 51463	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Glenn Langel	gklangel@netins.net	Templeton	Carroll	Iowa	Jonathan Heydon	Mitchell Langel	Signed	(1) The employer does not elect the employers’ liability coverage.	Glenn Langel	gklangel@netins.net	Owner	Templeton	Carroll	Iowa	Jonathan Heydon	Mitchell Langel	Signed
713	2021-11-05 10:41	Anonymous (not verified)	64.5.73.247	Mitchell Langel	Proprietorship	20581 300th St, Templeton IA 51463	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Mitchell Langel	gklangel@netins.net	Templeton	Carroll	Iowa	Jonathan Heydon	Lacey Marsh	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Langel	gklangel@netins.net	Owner	Templeton	Carroll	Iowa	Jonathan Heydon	Lacey Marsh	Signed
696	2021-10-28 10:33	Anonymous (not verified)	173.18.85.215	Saunders Construction	Proprietorship	7304 SW 14th St Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	Charles A Saunders	charlessaunders901@gmail.com	Des Moines	IA	United States	Ramona Mitchell	Rasheedah Gasaway	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Saunders	charlessaunders901@gmail.com	Owner	Des Moines	Polk	Iowa	Ramona Mitchell	Rasheedah Gasaway	Signed
697	2021-10-28 15:30	Anonymous (not verified)	208.126.114.236	bartman express	Limited Liability Company	1976 240th st bennett iowa 52721	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	bartin joesph steines	bartmanexpress@gmail.com	bennett	cedar	iowa	Robert theordore jarrett	dana marie shipler	Signed	(1) The employer does not elect the employers’ liability coverage.	bartin joesph steines	bartmanexpress@gmail.com	self	bennett	cedar	iowa	robert theordore jarrett	dana marie shipler	Signed
698	2021-10-28 16:09	Anonymous (not verified)	71.228.88.54	Warren Nelson	Proprietorship	2525 Nebraska Street, 106, Sioux City, Iowa 51104	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	Scott D. Nelson	scottdnelson@hotmail.com	Sioux City	Woodbury	Iowa	Wallace E Sheets	Abby McDermott	Signed	(1) The employer does not elect the employers’ liability coverage.	Beth L Sheets	w143bs@verizon.net	Daughter	Sarasota	Manatee	Florida	Wallace E. Sheets	Abby McDermott	Signed
699	2021-10-28 21:28	Anonymous (not verified)	75.162.104.116	Hild Construction, LLC	Limited Liability Company	6439 NE 5th Ave, Pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	Jason Hild	dirtsailor133@gmail.com	Pleasant Hill	Iowa	United States	Scott Dart	Michael Kramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Hild	dirtsailor133@gmail.com	Self	Pleasant Hill	Polk	United States	Scott Dart	Michael Kramer	Signed
690	2021-10-26 14:23	Anonymous (not verified)	65.144.174.26	Santiago Rojas	Proprietorship	1359 22nd st Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Santiago Rojas	rojassr09@gmail.com	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	Signed	(1) The employer does not elect the employers’ liability coverage.	Santiago Rojas	rojassr09@gmail.com	Owner	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	Signed
691	2021-10-26 14:54	Anonymous (not verified)	65.144.174.26	Alfonso Montoya	Proprietorship	2114 Nw Maple St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Alfonso Montoya	fonzflooring@gmail.com	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Alfonso Montoya	fonzflooring@gmail.com	Owner	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed
692	2021-10-26 14:58	Anonymous (not verified)	65.144.174.26	Jake Kenney	Proprietorship	3201 Hillsdale Dr. , Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Jacob Daniel Kenney	Jakedkenney@hotmail.com	Urbandale	Polk	Iowa	Abbey Kenney	Jory Ringler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Daniel Kenney	jakedkenney@hotmail.com	Owner	Urbandale	polk	ia	abbey kenney	jory ringler	Signed
693	2021-10-26 15:03	Anonymous (not verified)	65.144.174.26	Diamante Tile	Proprietorship	1403 Aspen Dr Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Octavio Bermudez	aerosobo@gmail.com	Des Moines	Dallas	Iowa	Antonia Bermudez	Sofia Piatt	Signed	(1) The employer does not elect the employers’ liability coverage.	Octavio Bermudez	aerosobo@gmail.com	Owner	Adel	Dallas	Iowa	Antonia Bermudez	Sofia Piatt	Signed
694	2021-10-26 15:30	Anonymous (not verified)	65.144.174.26	Escoto Tile	Proprietorship	6820 University Ave Windsor Heights, IA 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Salvador Escoto	escototile@gmail.com	Windsor Heights	Polk	Iowa	Claudia Veronica Ojeda Escoto	Josefina Escoto	Signed	(1) The employer does not elect the employers’ liability coverage.	Salvador Escoto	escototile@gmail.com	Owner	WINDSOR HEIGHTS	Polk	Iowa	Claudia Veronica Ojeda Escoto	Josefina Escoto	Signed
695	2021-10-26 17:22	Anonymous (not verified)	208.126.118.243	Godes Farms Trucking LLC	Limited Liability Company	1698 270th Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Mitchel R Godes	mitchelgodes@hotmail.com	Delmar	clinton	iowa	Dustin Kyarsgaard	Mitch Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchel R Godes	mitchelgodes@hotmail.com	owner	Delmar	Clinton	iowa	Dustin KKyarsgaard	Mitch Moore	Signed
688	2021-10-25 10:56	Anonymous (not verified)	75.91.173.195	Ami Westcott	Proprietorship	2672 F 52 Trail Parnell, IA 52325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-25	Ami Lynn Westcott	ami.westcott@gmail.com	Parmell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed	(1) The employer does not elect the employers’ liability coverage.	Ami Lynn Westcott	ami.westcott@gmail.com	self	Parnell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd Coralville IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed
706	2021-11-02 11:45	Anonymous (not verified)	50.82.130.211	Kierstyn Anest	Proprietorship	1200 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-25	Kierstyn Anest	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Kerstyn Anest	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
687	2021-10-22 11:07	Anonymous (not verified)	65.144.174.26	Fernando Garcia	Proprietorship	8952 Long Meadow Dr Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Fernando Garcia	gfernando5030@gmail.com	johnston	polk	Iowa	Javier Manriquez	Josefina Chavez	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Garcia	gfernando5030@gmail.com	Owner	Johnston	Polk	Iowa	Javier Manriquez	Josefina Chavez	Signed
847	2022-01-20 13:54	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Jesse Nitcher	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Nitcher	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
848	2022-01-20 13:56	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Chris Buseman	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Chris Buseman	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
849	2022-01-20 13:58	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Brandon Huisman	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Huisman	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
850	2022-01-20 14:03	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Justin Mehmen	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mehmen	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
851	2022-01-20 14:10	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Justin Mehmen	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mehmen	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
683	2021-10-20 09:39	Anonymous (not verified)	173.23.253.122	Superior Floors	Limited Liability Company	704 41st Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Ron Shannon	ronshannon3831@gmail.com	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Shannon	ronshannon3831@gmail.com	Self	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed
684	2021-10-20 13:25	Anonymous (not verified)	65.144.174.26	A and H Home Improvement	Limited Liability Company	600 NE 64th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Ivan A. Abel	aandhhomeimprovement@gmail.com	Des Moines	Polk	Iowa	Ken Krogman	Bruce Baumgarn	Signed	(1) The employer does not elect the employers’ liability coverage.	Ivan A. Abel	aandhhomeimprovement@gmail.com	Self	Des Moines	Polk	Iowa	Ken Krogman	Bruce Baumgarn	Signed
685	2021-10-20 14:14	Anonymous (not verified)	65.144.174.26	william c sawhill	Proprietorship	1625 Delaware Ave, Des Moines, 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	William C Sawhill	workorders@shoproyalflooring.com	Des Moines	Polk	Iowa	Nicholas W Sawhill	Jenny M Steben	Signed	(1) The employer does not elect the employers’ liability coverage.	William C Sawhill	workorders@shoproyalflooring.com	Self	Des Moines	Polk	Iowa	Nicholas W Sawhill	Jenny M Steben	Signed
686	2021-10-20 18:43	Anonymous (not verified)	173.27.196.168	Royal Flooring	Proprietorship	11801 Hickman Rd Urbandale, IA 50323 United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Joel Cisneros	auroraramos476@gmail.com	Des Moines	Polk county	Iowa	Aurora Cisneros	Maria Arroyo	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	cisnerostile476@gmail.com	Employee	Clive	Dallas	Iowa	Aurora Cisneros	Maria Arroyo	Signed
681	2021-10-19 15:44	Anonymous (not verified)	65.144.174.26	Humberto Albino	Proprietorship	3914 Aurora Ave Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-19	Humberto Albino	albinohumberto73@gmail.com	Des Moines	Polk	Iowa	Miguel Albino	Jesus Albino	Signed	(1) The employer does not elect the employers’ liability coverage.	Humberto Albino	albinohumberto73@gmail.com	Owner	Des Moines	Polk	Iowa	Miguel Albino	Jesus Albino	Signed
682	2021-10-19 16:15	Anonymous (not verified)	65.144.174.26	BBR Tile and Professional Installation LLC	Proprietorship	903 School Ave Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-19	Bertin Baltazar	baltarey2009@gmail.com	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Bertin Baltazar	baltarey2009@gmail.com	Owner	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed
677	2021-10-18 11:09	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Marcie R Gaylord	avisburlington@hotmail.com	Fort Madison	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	Lee	Iowa	Kim Delap	Teri Coleman	Signed
678	2021-10-18 11:26	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Linda Hunter	whitandpayt@gmail.com	Burlington	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	IA	United States	Kim Delap	Teri Coleman	Signed
679	2021-10-18 13:14	Anonymous (not verified)	173.18.22.217	Xscape Extreme Hard & Landscape	Proprietorship	3215 E 25th CT Bldg Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Mike Tapper	Tapper4981@gmail.com	Des Moines	Polk	IA	Lesa Dillon	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Tapp	Tapper4981@gmail.com	Owner	Des Moines	Des Moines	IA	Lesa Dillon	Kelly Coluzzi	Signed
680	2021-10-18 13:58	Anonymous (not verified)	166.181.86.88	Gerald Jerome	Proprietorship	2668 Wapsi Ridge Dr. Walker, IA 52352	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Gerald Jerome	geraldjerome373@ymail.com	Walker	IA	United States	Benjamin J Barkalow	James M. Barkalow	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerald Jerome	geraldjerome373@ymail.com	Self employed	Walker	Linn	Iowa	Benjamin J Barkalow	James M Barkalow	Signed
674	2021-10-15 09:43	Anonymous (not verified)	173.29.63.3	Peter Hawley	Proprietorship	524 n galena ave, Wyoming Illinois 61491	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-15	Peter Anthony Hawley	hawleypete801@gmail.com	Wyoming	Stark	Illinois	Elizabeth Doreen Hawley	Ian Matthew Esmoil	Signed	(1) The employer does not elect the employers’ liability coverage.	Peter Anthony Hawley	hawleypete801@gmail.com	Self	Wyoming	Stark	IL	Elizabeth Doreen Hawley	Ian Matthew Esmoil	Signed
675	2021-10-15 11:22	Anonymous (not verified)	75.162.156.37	MCG FLOORING, LLC	Limited Liability Company	2115 CARPENTER AVE DES MOINES IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-15	GABRIELA GOMEZ	MCGFLOORINGLLC@GMAIL.COM	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(1) The employer does not elect the employers’ liability coverage.	MCG FLOORING, LLC	MCGFLOORINGLLC@GMAIL.CON	OWNER	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
676	2021-10-15 11:29	Anonymous (not verified)	75.162.156.37	MCG FLOORING, LLC	Limited Liability Company	2115 CARPENTER AVE DES MOINES, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-15	MANUEL CONTRERAS BERNAL	MCGFLOORINGLLC@GMAIL.COM	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	MCG FLOORING, LLC	MCGFLOORINGLLC@GMAIL.CON	OWNER	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
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
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
669	2021-10-13 08:24	Anonymous (not verified)	64.191.11.62	E360 Building Company, Inc.	Proprietorship	PO Box 363, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-13	Mark Miller	mark@e360buildingco.com	Cedar Falls	Black Hawk	Iowa	Laetyn Miller	Grant Williamson	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Miller	markm@cfu.net	Self	Cedar Falls	Black Hawk	Iowa	Laetyn Miller	Grant Williamson	Signed
670	2021-10-13 12:30	Anonymous (not verified)	173.19.179.111	MULLER TRANSPORT LLC	Limited Liability Company	2083 260TH ST MILFORD, IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-13	PAUL MULLER	MULLERTANSPORTLLC@GMAIL.COM	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	PAUL MULLER	JOEL@WALKERINSURANCEIA.COM	SELF	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
671	2021-10-13 15:00	Anonymous (not verified)	173.23.180.179	Larry and Company Inc.	Proprietorship	7239 Osage Road, Waterloo, Iowa 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-13	Larry Rust	larryandcoinc@hotmail.com	Waterloo	Black Hawk	Iowa	Lisa Kay Buls	Kevin Thomas Buls	Signed	(1) The employer does not elect the employers’ liability coverage.	Larry Alan Rust	larryandcoinc@hotmail.com	Self	Waterloo	Black Hawk	Iowa	Lisa Kay Buls	Kevin Thomas Buls	Signed
668	2021-10-12 16:11	Anonymous (not verified)	173.18.22.217	Mo's Cleaning LLC	Limited Liability Company	1412 E 23rd St Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-12	Melissa Jones	commcleanwithme123@gmail.com	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Jones	commcleanwithme123@gmail.com	Owner	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed
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
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
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
663	2021-10-04 09:45	Anonymous (not verified)	166.181.80.1	Matthew Winters	Proprietorship	9220 Summit Dr Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-04	Matthew Winters	mattwinters55@gmail.com	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Winters	mattwinters55@gmail.com	Self	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed
662	2021-10-01 16:05	Anonymous (not verified)	174.242.224.18	Troy bryan	Limited Liability Company	2800 68th st urbandale Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-01	Troy bryan	tbryan0015@gmail.com	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Troy bryan	tbryan0015@gmail.com	Owner	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed
660	2021-09-30 14:15	Anonymous (not verified)	172.58.86.219	LeafFilter	Limited Liability Company	3060 SE Grimes Blvd. Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-30	Mohammed Albayati	mmm2002faris@yahoo.com	West Des Moines	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Albayati	albayatim28@gmail.com	Employee	Grimes	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed
672	2021-10-13 16:05	Anonymous (not verified)	75.162.218.218	Arturos Interiors LLC	Limited Liability Company	3305 se 22nd apt 15 Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-29	Arturo mejia	arturomcruz20@hotmail.com	Des Moines	polk	IA	yolanda mendoza	liliana sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Arturo Mejia	arturomcruz20@hotmail.com	member	Des Moines	polk	IA	Yolanda Mendoza	lialiana sanchez	Signed
659	2021-09-28 11:02	Anonymous (not verified)	172.58.83.48	Sean Goodwin	Limited Liability Company	8843 primrose lane Clive IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-28	Sean Goodwin	simplemanmx@gmail.com	Clive	IA	United States	Kaitlyn meier	Tina meier	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Goodwin	simplemanmx@gmail.com	Self	Clive	Polk	Iowa	Kaitlyn meier	Tina meier	Signed
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
657	2021-09-27 13:55	Anonymous (not verified)	167.142.136.87	Crosser Electric,Inc	Partnership	PO Box 204 Eldora, Iowa 50627	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-27	Marlyn D Crosser	vhalvorsen@aol.com	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed	(1) The employer does not elect the employers’ liability coverage.	Vicki Halvorsen	vhalvorsen@aol.com	Partner andf sec/treasurer	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed
658	2021-09-27 14:01	Anonymous (not verified)	167.142.136.87	Crosser Electric, Inc	Partnership	PoBox 204 Eldora, Iowa 50627	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-27	Victoria Halvorsen	vhalvorsen@aol.com	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed	(1) The employer does not elect the employers’ liability coverage.	Victoria or Vicki Halvorsen	vhalvorsen@aol.com	Partner sec/treasure	Eldora	Hardin	Iowa	Laura Kramer	Melissa Sison	Signed
656	2021-09-25 09:20	Anonymous (not verified)	173.20.172.87	Daugherty Construction LLC	Limited Liability Company	1985 SE Willow Brook Dr, Waukee, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-25	Joseph Ryan Daugherty	jdaugherty1024@yahoo.com	Waukee	Dallas	Iowa	Sarah Lynn Daugherty	Timothy Joe Daugherty	Signed	(1) The employer does not elect the employers’ liability coverage.	Daugherty Construction LLC	jdaugherty1024@yahoo.com	Owner/President	Waukee	Dallas	Iowa	Sarah Lynn Daugherty	Timothy Joe Daugherty	Signed
655	2021-09-24 15:28	Anonymous (not verified)	67.212.111.166	S Miller Painting LLC	Limited Liability Company	1135 Barnett Drive, Cedar Falls, Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-24	Steven David Miller	stevendm24@hotmail.com	Cedar Falls	Black Hawk	Iowa	Steve Koger	Mark Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Allen koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk	Iowa	Steve Koger	Mark Miller	Signed
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
653	2021-09-23 15:03	Anonymous (not verified)	72.46.189.33	Feldkamp Farms Inc	Partnership	5382 170th St Sibley IA 51249	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-23	Harold P Feldkamp	joan@ellerbroekandassociates.com	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed	(1) The employer does not elect the employers’ liability coverage.	James Wade Ellerbroek Jr	WADE@ELLERBROEKANDASSOCIATES.COM	Agent only	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed
654	2021-09-24 15:08	Anonymous (not verified)	199.247.64.87	Steve Porter DBA Precision Striping	Proprietorship	408 Embassy Ct. Sergeant Bluff, IA 51054	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-23	Steve Porter	steve.porter2710@gmail.com	Sergeant Bluff	Woodbury	Iowa	Josh Nichols	Steve Porter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jana Reich	JNeuzil@reichpainting.com	Office Manager	Sioux City	Woodbury	Iowa	Josh Nichols	Steve Porter	Signed
650	2021-09-22 20:46	Anonymous (not verified)	174.198.68.116	Freedom field services	Limited Liability Company	6285 n 67 ave w baxter iowa 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
651	2021-09-22 21:05	Anonymous (not verified)	174.198.68.116	Freedom field services LLC	Limited Liability Company	6285 n 67 ave w. BAXTER IOWA 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
652	2021-09-22 21:52	Anonymous (not verified)	209.152.66.250	Robert Stutzman	Limited Liability Company	33784 Hwy 22 Keota, IA 25548	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	Robert L Stutzman	bnbstutzman@gmail.com	Keota	Keokuk	Iowa	Jo Edgington	Amber Gent	Signed	(1) The employer does not elect the employers’ liability coverage.	Sandra K Stutzman	iafarmgirl90@gmail.com	Daughter	Keota	Keokuk	Iowa	Jo Edgington	Amber Gent	Signed
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
646	2021-09-20 08:54	Anonymous (not verified)	173.24.107.209	QCA Professional Contractors	Limited Liability Company	3314 67th Ave, Moline, IL. 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-20	Allan Celada	allancelada@qcaprocontractors.com	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Allan Celada	allancelada@qcaprocontractors.com	self	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	Signed
647	2021-09-20 10:37	Anonymous (not verified)	173.29.34.49	Brandon Jones	Proprietorship	2043 3x Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-20	Brandon Dederick Jones	Kaleb0430jones@gmail.com	East Moline	United States	Illinois	Brandon Jones	Brandon Jones	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Dederick Jones	Kaleb0430jones@gmail.com	self	East Moline	United States	Illinois	Brandon Jones	Brandon Jones	Signed
645	2021-09-18 09:47	Anonymous (not verified)	208.68.114.238	CHL Roofing & Siding Inc	Proprietorship	509 1/2 E A St, West Liberty, IA 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-18	Fabian Galvan Rodriguez	fgalvanglez14@gmail.com	West Liberty	Muscatine	Iowa	Karina A Beltran	Nereida Velez	Signed	(1) The employer does not elect the employers’ liability coverage.	Fabian Galvan Rodriguez	fgalvanglez14@gmail.com	Self	West Liberty	Muscatine	Iowa	Karina A Beltran	Nereida Velez	Signed
641	2021-09-17 09:16	Anonymous (not verified)	72.255.121.118	Osman Gonzalez-Sarceno	Proprietorship	1403 Aspen Dr Adel, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-17	Osman Gonzalez-Sarceno	workorders@shoproyalflooring.com	Des Moines	Polk	IA	Melissa Bolanos	Brianna Fuller	Signed	(1) The employer does not elect the employers’ liability coverage.	Osman Gonzalez-Sarceno	workorders@shoproyalflooring.com	Owner	Des Moines	Polk	Iowa	Melissa Bolanos	Brianna Fuller	Signed
642	2021-09-17 11:09	Anonymous (not verified)	167.142.95.56	Preferred Properties of Iowa, Inc.	Limited Liability Company	500 W. Temple St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-17	Daniel Zech	dan.ppi@gmail.com	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Zech	dan.ppi@gmail.com	Owner	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed
643	2021-09-17 11:17	Anonymous (not verified)	167.142.95.56	Preferred Properties of Iowa, Inc.	Limited Liability Company	500 W. Temple St., Lenox, IA 50851	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-17	Mark Pearson	mdpearson88@gmail.com	Corning	Adams	Iowa	Ron Travis	Maury Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Zech	dan.ppi@gmail.com	Owner	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed
644	2021-09-17 11:20	Anonymous (not verified)	167.142.95.56	Preferred Properties of Iowa, Inc.	Limited Liability Company	500 W. Temple St., Lenox, IA 50851	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-17	Brennan Kester	mdpearson88@gmail.com	Corning	Taylor	Iowa	Ron Travis	Maury Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Zech	dan.ppi@gmail.com	owner	Lenox	Taylor	Iowa	Ron Travis	Maury Moore	Signed
640	2021-09-16 22:43	Anonymous (not verified)	97.125.255.204	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-16	Mackinley Charles Morgan	Morgangroupllc@gmail.com	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Mackinley Charles Morgan	Morgangroupllc@gmail.com	Owner of company	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed
648	2021-09-21 10:03	Anonymous (not verified)	97.125.32.164	Manuel Morales	Proprietorship	1302 13th St Des Moines, Iowa 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-15	Manuel Morales	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Manuel Morales	deb@picowa.com	subcontractor	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
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
634	2021-09-10 13:41	Anonymous (not verified)	173.23.145.231	julio medina	Proprietorship	609 boyd st. des moines, iowa 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-10	julio medina	medinajulio10001@gmail.com	des moines	polk	iowa	jose rivas	Virginia Gomez	Signed	(1) The employer does not elect the employers’ liability coverage.	Julio Medina	medinajulio10001@gmail.com	owner	des moines	polk	iowa	jose Rivas	Virginia Gomez	Signed
635	2021-09-10 13:41	Anonymous (not verified)	166.181.84.226	JZH Roofing Specialists LLC	Limited Liability Company	2127 Swan Dr, Norwalk, Iowa. 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-10	Jayme Alexander Christian Heiselman	wrkhrd2plyhrd04@gmail.com	Norwalk	Warren	Iowa	Melanie Handy	Jesse Hagge	Signed	(1) The employer does not elect the employers’ liability coverage.	Jayme Alexander Christian Heiselman	wrkhrd2plyhrd04@gmail.com	Single member	Norwalk	Warren	Iowa	Melanie Handy	Jesse Hagge	Signed
636	2021-09-10 14:56	Anonymous (not verified)	173.19.179.111	SHANNON SUNDINE	Proprietorship	513 16TH ST SPIRIT LAKE IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-10	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
637	2021-09-10 15:15	Anonymous (not verified)	204.155.61.217	Duwa Waterproofing LLC	Limited Liability Company	1548 150th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-10	Stacy Duwa	duwawaterproofing@gmail.com	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	owner	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed
632	2021-09-07 13:42	Anonymous (not verified)	50.82.130.211	Thomas Mann	Proprietorship	401 Miners Street, Parkersburg, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-09	Thomas Mann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Mann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1401	2022-12-23 09:07	Anonymous (not verified)	75.162.43.221	Capital Express	Limited Liability Company	Council is Chris Blunk out of omaha NB.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2021-09-09	Nicholas Michelfelder	nicmichelfelder@gmail.com	8018 Valdez Circle	polk	iowa	Ted Michelfelder	lucy Sanderson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Chris Blunk	cblunk@harrislawomaha.com	None	1400 SE gateway Dr. 105	Polk	IA	Theodore Michelfelder	Rick Isacson	Signed
633	2021-09-08 10:35	Anonymous (not verified)	208.95.1.97	BAJ Flooring, LLC	Limited Liability Company	31533 Castle Ct. Dyersville, IA. 52040-7600	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-09-08	Brian Jacque	JacqueBrian18@gmail.com	Dyersville	Dubuque	Iowa	Stephen J. Schluter	Paula Fitzgerald	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Brian A. Jacque	JacqueBrian18@gmail.com	LLC MEMBER	Dyersville	DUBUQUE	IOWA	Stephen J. Schlueter	Stephen J. Schlueter	Signed
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
628	2021-09-01 09:39	Anonymous (not verified)	204.155.61.217	Utzinger Epoxy & Concrete, LLC	Limited Liability Company	1595 Highway 1 Washington, Iowa 52353	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Troy Utzinger	tbutzinger99@kctc.net	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Utzinger	tbutzinger99@kctc.net	owner	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
629	2021-09-01 09:44	Anonymous (not verified)	204.155.61.217	Thrapp Electric	Proprietorship	708 2nd Street Wellman, Iowa 52356	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Jay Thrapp	socketman5555@hotmail.com	Wellman	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Thrapp	socketman5555@hotmail.com	Owner	Wellman	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
630	2021-09-01 19:29	Anonymous (not verified)	97.125.133.79	Aaron J. Rosenbaum	Proprietorship	2005 Pine St, Granger, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Aaron J. Rosenbaum	aabaum7@gmail.com	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Rosenbaum	aabaum7@gmail.com	self	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed
626	2021-08-31 11:39	Anonymous (not verified)	166.181.81.253	Birds landscape maintenance LLC	Limited Liability Company	1307 w 4th st south	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-31	Michael Alan bird	birdslawn@hotmail.com	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Alan bird	birdslawn@hotmail.com	Same - owner	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed
627	2021-08-31 16:12	Anonymous (not verified)	173.18.16.129	D's Home Improvement	Limited Liability Company	665 27th St Des Moines IA 50312	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-31	Dustin Mitchell	dustinmitchell8855@gmail.com	Des Moines	Polk	Iowa	Lesa Reeves	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Mitchell	dustinmitchell8855@gmail.com	Owner	Des Moines	Polk	IA	Lesa Reeves	Kelly Coluzzi	Signed
623	2021-08-30 15:03	Anonymous (not verified)	174.198.77.231	Joe Dawson	Proprietorship	1088, Dogwood Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Joe R Dawson	joerdawson@gmail.com	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Joe R Dawson	joerdawson@gmail.com	Owner	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed
624	2021-08-30 15:53	Anonymous (not verified)	174.253.66.113	Leaf Home Solutions LLC	Limited Liability Company	1595 Georgetown Rd.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Chad York	Cyork027@gmail.com	Davenport	Scott	Iowa	Chad York	Adam Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Coleman	ARColeman@leafhome.com	Recruiter	Hudson	Summit	Ohio	Chad York	Adam Coleman	Signed
625	2021-08-30 20:39	Anonymous (not verified)	173.16.140.101	Phthalo Consulting LLC	Limited Liability Company	2917 47th St, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Angela Stone-Wiegert	angela@phthaloconsulting.com	Des Moines	Polk	Iowa	Sonya Shippy	Kenny Shippy	Signed	(1) The employer does not elect the employers’ liability coverage.	Angela Stone-Wiegert	angela@phthaloconsulting.com	Owner	Des Moines	Polk	Iowa	Sonya Shippy	Kenny Shippy	Signed
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
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
616	2021-08-23 13:14	Anonymous (not verified)	173.25.153.19	Levon	Proprietorship	210 S 41st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Levon shheba	sheebalevon@gmail.com	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed	(1) The employer does not elect the employers’ liability coverage.	Levon sheeba	sheebalevon@gmail.com	Myself	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed
617	2021-08-23 13:58	Anonymous (not verified)	172.58.84.152	Jose barrientos	Proprietorship	1844 n tony ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-23	Jose Barrientos	70barrientos70@gmail.com	Wichita	Sedwick	Kansas	Roberto valle	Juan lopez	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jose barrientos	70barrientos70@gmail.com	Employer	Wichita	Sedwick	Kansas	Vladimir faustino	Rene Grande	Signed
618	2021-08-23 15:17	Anonymous (not verified)	173.17.131.91	Leaffilter North of Iowa, LLC	Proprietorship	5650 NW Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Jorge Meraz	jmaraz961@gmail.com	2906 e madison avenue	Des moines	IA	Jisel chaves	Melvin arevalo	Signed	(1) The employer does not elect the employers’ liability coverage.	Jorge meraz	jmeraz961@gmail.com	Self	Des moines	Des moine	IA	Jusel chavez	Melvin arevalo	Signed
620	2021-08-26 16:26	Anonymous (not verified)	75.162.146.246	Daniel Meza Reyes	Proprietorship	1640 E Army Post RD Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Daniel Meza Reyes	danielmr9247@gmail.com	Des Moines	polk	IA	Yolanda Mendoza	Liliana Sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Meza Reyes	danielmr9247@gmail.com	self	Des Moines	polk	IA	Yolanda Mendoza	Liliana Sanchez	Signed
611	2021-08-19 15:23	Anonymous (not verified)	97.125.53.119	Rogelio Lopez Casillas	Proprietorship	1175 Office Park Road Apt 109 WDM, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-21	Rogelio Lopez Casillas	deb@piciowa.com	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Rogelio Lopez Casillas	deb@piciowa.com	subcontractor	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed
612	2021-08-19 21:50	Anonymous (not verified)	50.82.65.174	33z Racing,, LLC	Limited Liability Company	307 N Park Ave, New Sharon, Iowa 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	James Dean VanderBeek	jvanderbeek@plbco.com	New Sharon	Mahaska	Iowa	Margaret Ratcliff	Billy Blake	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara M VanderBeek	bvanderbeek33z@gmail.com	Spouse	New Sharon	Mahaska	Iowa	Margaret Ratcliff	Billy Blake	Signed
613	2021-08-19 21:54	Anonymous (not verified)	50.82.65.174	33z Racing, LLC	Limited Liability Company	307 N Park Ave, New Sharon, Iowa 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Zackery J VanderBeek	zackvanderbeek@gmail.com	New Sharon	Mahaska	IA	Margaret Ratcliff	Billy Blake	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara M VanderBeek	bvanderbeek33z@gmail.com	Mother	New Sharon	Mahaska	IA	Margaret Ratcliff	Billy Blake	Signed
614	2021-08-20 12:20	Anonymous (not verified)	172.58.235.242	Darren Qualls	Proprietorship	1515 Dewitt St. Ellsworth. IA 50075	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Darren Wade Qualls	d.qualls@outlook.com	Ellsworth	Hamilton	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed	(1) The employer does not elect the employers’ liability coverage.	Darren Wade Qualls	d.qualls@outlook.com	Self/Proprietor	Ellsworth	IA	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed
615	2021-08-20 16:22	Anonymous (not verified)	50.81.152.147	CPIA Home Specialists LLC	Limited Liability Company	1214 13th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Melvin Benitez	Benitezmelvin0@gmail.com	Des Moines	Iowa	United States	Salvador Benitez	Zoila Benitez	Signed	(1) The employer does not elect the employers’ liability coverage.	Melvin Benitez	Benitezmelvin0@gmail.com	Owner	Des Moines	Iowa	United States	Salvador Benitez	Zoila Benitez	Signed
610	2021-08-18 11:15	Anonymous (not verified)	172.58.84.99	LeafFilter North LLC	Partnership	866 40th ave bettendorf iowa 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-18	Thomas R Fuller	tomstl001@yahoo.com	DAVENPORT	Iowa	Iowa	Bob phillips	Julie fuller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Regional field recruiter	Bettendorf iowa	Scott	Iowa	Warren crow	Jordan lloyd	Signed
606	2021-08-17 12:25	Anonymous (not verified)	69.57.199.231	Precision Painting	Proprietorship	507 Broad St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed
607	2021-08-17 12:31	Anonymous (not verified)	69.57.199.231	Precsion Painting	Proprietorship	507 Broad St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(1) The employer does not elect the employers’ liability coverage.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed