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:
90	2020-03-13 15:44	Anonymous (not verified)	173.24.190.134	Heath Householder	Limited Liability Company	2 N Huron Street, Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-07	Heath Householder	heath679@live.com	Emmetsburg	Palo Alto	Iowa	Scott Wirtz	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Householder	heath679@live.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Scott Wirtz	Candie Clark	Signed
91	2020-03-13 15:51	Anonymous (not verified)	173.24.190.134	Small Town RV, LLC	Limited Liability Company	112 Miller Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-09	Heath Sabin	sales@smalltownrv.com	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Sabin	sales@smalltownrv.com	Member of LLC	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed
939	2022-02-28 13:46	Anonymous (not verified)	173.23.228.17	H & T Ziesman, LLC	Limited Liability Company	575 Nuthatch Iowa Falls IA 50126	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-28	Heath Ziesman	heathziesman87@gmail.com	Iowa Falls	Franklin	Iowa	Jeanne Rieks	Kelly Reed	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath ZIesman	heathziesman87@gmail.com	Owner	Iowa Falls	Franklin	Iowa	Jeanne Rieks	Kelly Reed	Signed
354	2021-01-11 15:04	Anonymous (not verified)	71.199.85.251	Heather Hampton Cooper Consulting, llc	Limited Liability Company	412 Mango Cir, Saint Augustine, Florida 32095	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-11	Heather H Cooper	hcooper1@comcast.net	Saint Augustine	Saint Johns	FL	Terry l. Cooper	Lauren Rivera	Signed	(1) The employer does not elect the employers’ liability coverage.	Heather H Cooper	hcooper1@comcast.net	Owner	Saint Augustine	Saint Johns	FL	Terry Cooper	Lauren Rivera	Signed
43	2020-01-27 09:23	Anonymous (not verified)	71.199.85.251	ATW Training	Limited Liability Company	4414 114th Street, Urbandale Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-25	Heather Hampton Cooper	hcooper1@comcast.net	Saint Augustine	Saint Johns	Florida	Terry Lee Cooper	Stacy Thatcher	Signed	(1) The employer does not elect the employers’ liability coverage.	Lynn Roberts	Lynne@atwtraining.com	HR	Des Moines	Polk	Iowa	Cathy Belmont	Mark Purcell	Signed
385	2021-02-07 12:43	Anonymous (not verified)	173.17.12.148	H@E roofing LLC	Limited Liability Company	1912 Burson street Des Moines is 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-04	Heather Hickman	hratherhickman@gmail.com	Des moines	Polk	Iowa	Jerry freeborn	Ivan torres	Signed	(1) The employer does not elect the employers’ liability coverage.	Heather Hickman	hratherhickman@gmail.com	Self	Des moines	Polk	Iowa	Jerry freeborn	Ivan torres	Signed
2084	2024-03-08 15:18	Anonymous (not verified)	94.188.207.230	Heidi Vincent	Proprietorship	2213 SW White Birch Dr, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	Heidi Vincent	jared.vincent@insurancestationinc.com	Ankeny	Polk	Iowa	Jared Vincent	Colton Horak	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Jared Vincent	Colton Horack	Signed
314	2020-11-13 10:18	Anonymous (not verified)	66.172.192.197	Helaine W. Sherman Trust	Proprietorship	P.O. Box 717, Sioux City, Iowa 51102	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-13	Helaine W. Sherman Trust, A.F. Baron, Trustee	afbaron@baronsar.com	Sioux City	Woodbury	Iowa	Joni L. Stieneke	Gregory N. Lohr	Signed	(1) The employer does not elect the employers’ liability coverage.	Helaine W. Sherman Trust, A.F. Baron, Trustee	afbaron@baronsar.com	Trustee of Trust	Sioux City	Woodbury	Iowa	Joni L. Stieneke	Gregory N. Lohr	Signed
924	2022-02-17 13:02	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Henry O. Miller	accounting@robertseddy.com	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
249	2020-08-28 13:06	Anonymous (not verified)	97.125.184.147	Supernova Construction LLC	Proprietorship	4665 171st St, Urbandale, IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-28	Heraclio A Ayala	heraclio.ayala@yahoo.com	Urbandale	Dallas	IA	Ricardo Alverio	Valentin Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Heraclio Ayala	heraclio.ayala@yahoo.com	Sole Member	Urbandale	Dallas	IA	Ricardo Alverio	Valentin Garcia	Signed
504	2021-05-06 15:43	Anonymous (not verified)	75.162.84.34	Erreguin Labra Roofing LLC	Limited Liability Company	642 S Washington Ave Mason City IA 50401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-06	Hilario Labra Trejo	erreguin06@gmail.com	mason city	cerro gordo	Iowa	Liliana Sanchez	Yolanda Mendoza	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Fernando Erreguin	Erreguin06@gmail.com	member	Mason city	cerro gordo	iowa	Liliana sanchez	yolanda mendoza	Signed
61	2020-02-13 08:44	Anonymous (not verified)	71.28.216.94	Cyclone Captioning, Inc	Proprietorship	8866 W 122nd Street N, Mingo, IA 50168	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-13	Holli L. Schneider	Hlschneid87@gmail.com	Mingo	Jasper	IA	Dan Herrin	Minda Dearden	Signed	(1) The employer does not elect the employers’ liability coverage.	Holli Schneider	hlschneid87@gmail.com	President of Proprietorship	Mingo	Jasper	IA	Dan Herrin	Minda Dearden	Signed
889	2022-02-03 14:52	Anonymous (not verified)	207.177.96.173	Stecker Rentals Inc.	Limited Liability Company	1439 Kate Shelley Dr. Boone IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-03	Holly Stecker	hollystecker6@gmail.com	Boone	Boone	IA	Shana Mallas	Laura Hutchcroft	Signed	(1) The employer does not elect the employers’ liability coverage.	Holly Stecker	hollystecker6@gmail.com	Owner	Boone	Boone	IA	Shana Mallas	Laura Hutchcroft	Signed
1719	2023-07-01 21:34	Anonymous (not verified)	94.188.207.223	Granite & More	Limited Liability Company	4730 Tremont ave Davenport Iowa 52807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-01	Hong Le	granite732@yahoo.com	Davenport	Scott	Iowa	Jin Chen	Betty Song	Signed	(1) The employer does not elect the employers’ liability coverage.	Jin Chen	clteam563@gmail.com	Manager	Bettendorf	Scott	Iowa	Jin Chen	Betty Song	Signed
1526	2023-03-21 12:24	Anonymous (not verified)	94.188.207.223	Quad Cities Transport Inc	Proprietorship	1106 46th ave Rock Island IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-21	Howard Davis	qctranaportinc@gmail.com	East Moline	Rock Island	Illinois	Ricky Oconner	Patrick Watkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Howard Davis	hdenterprisesinc14@gmail.com	Owner	East Moline	Rock Island	Illinois	Patrick Watkins	Ricky Oconner	Signed
1527	2023-03-22 08:35	Anonymous (not verified)	94.188.205.167	Quad Cities Transport Inc	Proprietorship	1106 46th ave Rock Island IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-21	Howard Rick Clark Davis	hdenterprisesinc14@gmail.com	East Moline	Rock Island	IL	Patrick Watkins	Ricky Oconner	Signed	(1) The employer does not elect the employers’ liability coverage.	Howard Davis	qctransportinc@gmail.com	Owner	East Moline	Rock Island	Illinois	Ricky Oconner	Patrick Watkins	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
1412	2023-01-06 12:38	Anonymous (not verified)	72.255.93.91	Espindola Painting Services	Proprietorship	4701 Woodland Ave Unit 3, West Des Moines, IA 50266	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Hugo Espindola	bmoellers@thebookeepersinc.net	Des Moines	Polk	IA	Jenny Espindola	Gary Cort	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Moellers	bmoellers@thebookkeepersinc.net	Accountant	Des Moines	Polk	IA	Jenny Espindola	Gary Cort	Signed
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
1563	2023-04-11 08:49	Anonymous (not verified)	94.188.205.168	Ibrahim Sehic	Proprietorship	4052 Lafayette Rd, Evansdale, IA 50707	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-11	Ibrahim Sehic	bacosidig@gmail.com	Evansdale, IA	Black Hawk County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Warren Crow	Signed
353	2021-01-11 14:38	Anonymous (not verified)	66.188.136.150	Igor Curguz	Proprietorship	927 1/2 W Grand Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-11	Igor Curguz	kschumacher@tricorinsurance.com	Beloit	Rock	WI	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Igor Curguz	kschumacher@tricorinsurance.com	Same	Beloit	Rock	WI	Russell Masartis	Nancy Wortley	Signed
1444	2023-02-07 14:57	Anonymous (not verified)	173.21.126.4	Rhino Roofing	Limited Liability Company	2534 Garfield 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.	2021-02-07	Irwins Martinez	rhinoroofingsiding21@gmail.com	Des Moines	Polk	Iowa	Sara Titus	Justin Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Irwin Martinez	rhinoroofing21@gmail.com	Self	Des Moines	Polk	Iowa	Sara Titus	Justin Williams	Signed
221	2020-08-03 12:03	Anonymous (not verified)	167.142.196.238	Israel Moreno	Proprietorship	Po Box 186 Williams, IA 50271	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-12	Israel Moreno	mikjuniormoreno@hotmail.com	Williams	Hamilton	Iowa	Justin J Malloy	Myndi Grimsley	Signed	(1) The employer does not elect the employers’ liability coverage.	Israel Moreno	mikjuniormoreno@hotmail.com	owner	Williams	Hamilton	Iowa	Justin J Malloy	Myndi Grimsley	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
347	2020-12-31 13:44	Anonymous (not verified)	66.129.217.166	Issis Melissa Nunez	Proprietorship	2128 S Riverside Dr. Trl 57, Iowa City, IA 52246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-01	Issis Melissa Nunez	tonypauljohnson@yahoo.com	Iowa City	IA	United States	Anthony Johnson	Olvin Lanza	Signed	(1) The employer does not elect the employers’ liability coverage.	Issis Melissa Nunez	tonypauljohnson@yahoo.com	Owner	Iowa City	IA	United States	Anthony Johnson	Olvin Lanza	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
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
2139	2024-04-08 10:35	Anonymous (not verified)	94.188.205.168	Professional Hardwood Floors LLC	Limited Liability Company	14858 118th 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.	2024-04-08	Ivan Pilat	professionalfloors@ymail.com	Indianola	Warren	iowa	Mark Kapysten	Vladmir Orbedan	Signed	(1) The employer does not elect the employers’ liability coverage.	Ivan Pilat	professionalfloors@ymail.com	Self	Indianola	Warren	Iowa	Mark Kapysten	Vladmir Orbedan	Signed
1862	2023-10-05 14:30	Anonymous (not verified)	94.188.207.225	J trinidad Garcia Ferrer	Proprietorship	3722 SE 14th St Apt 9 Des Moines, Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-01	J Trinidad Garcia Ferrer	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	J trinidad Garcia Ferrer	deb@piciowa.com	self	Des Moines	Polk	IOwa	Deb Stratton	Martin Pinon	Signed
38	2020-01-18 12:15	Anonymous (not verified)	206.109.174.199	BJS Frenchies, LLC	Limited Liability Company	20081 Highway J 46 Centerville Iowa 52544	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	J. Jamie Tracy	jamiespuppies@yahoo.com	Centerville	Appanoose	Iowa	Misty O'Hair	Casey Leach	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce E Tracy	jamiespuppies@yahoo.com	Husband and Co Owner	Centerville	Appanoose	Iowa	Misty O'Hair	Casey Leach	Signed
1424	2023-01-17 17:34	Anonymous (not verified)	173.191.246.189	Jabe Ramsey	Proprietorship	216 South Park Street Osceola, IA 50213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-17	Jabe Hatfield Ramsey	jaberamsey@icloud.com	Osceola	IA	United States	Sofia Contreras	Katie Anne Carson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jabe Ramsey	jaberamsey@icloud.com	ME	Osceola	Clarke	IOWA	Sofia Contreras	Katie Anne Carson	Signed
1890	2023-11-01 19:22	Anonymous (not verified)	94.188.207.228	JACK SCHADE	Proprietorship	911 Broad St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	jack allan schade	jackschade@yahoo.com	Plymouth	IA	IA	jack allan schade	jack allan schade	Signed	(1) The employer does not elect the employers’ liability coverage.	jack allan schade	jackschade@yahoo.com	self	Plymouth	IA	IA	jack allan schade	jack allan schade	Signed
305	2020-11-02 08:40	Anonymous (not verified)	204.124.192.31	JPS Framing	Proprietorship	102 WALL AVE - DES MOINES IA 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-02	JACKELYN SANCHEZ	JPSFRAMING629@GMAIL.COM	DES MOINES	POLK	IOWA	ROGELIO SANCHEZ	DOMINIQUE SANCHEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	JUAN SERRANO	JPSFRAMING629@GMAIL.COM	EMPLOYER	DES MOINES	POLK	IOWA	ROGELIO SANCHEZ	DOMINIQUE SANCHEZ	Signed
1531	2023-03-24 08:40	Anonymous (not verified)	94.188.207.228	Schneiter Insurance and Financial Solutions	Limited Liability Company	900 E 3RD ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-01	Jackie Schneiter	grlschneiter@gmail.com	MONTICELLO	IA	United States	Ronald Schneiter	Reagan Schneiter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacqueline Schneiter	jackie@we78ins.com	owner	ANAMOSA	JONES	IOWA	RONALD SCHNEITER	REAGAN SCHNEITER	Signed
500	2021-04-29 13:09	Anonymous (not verified)	204.155.61.217	JWJ Home Remodeling LLC	Limited Liability Company	16915 Weaver Lake Dr, Maple Grove MN 55311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-29	Jackson Janzen	jacksonjanzen@hailmayday.com	Maple Grove	hennepin	MN	Ashley Kraft	DocuSign	Signed	(1) The employer does not elect the employers’ liability coverage.	Jackson Janzen	jacksonjanzen@hailmayday.com	Owner	Maple Grove	Hennepin	MN	Ashley Kraft	DocuSign	Signed
1825	2023-08-30 11:16	Anonymous (not verified)	94.188.207.225	Quad City Glass	Proprietorship	1330 N Harrison St. Davenport, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-30	Jacob Brown	quadcityglass@gmail.com	Davenport	Scott	IOWA	na	na	Signed	(1) The employer does not elect the employers’ liability coverage.	Quad City Glass	Quadcityglass@gmail.com	employee	Davenport	Scott	IOWA	na	na	Signed
1033	2022-04-05 09:36	Anonymous (not verified)	75.89.4.2	KG Land Works	Limited Liability Company	PO Box 931 Barnsdall, Oklahoma 74002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Jacob Curtis Kelley	jacobkelley730@gmail.com	Barnsdall	Osage	Oklahoma	Josiah Daniel Gott	Ainsley Noelle Cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Gardner	kglandworks@gmail.com	Owner	Barnsdall	Osage	Oklahoma	Josiah Daniel Gott	Wyatt Ray Slone	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
1617	2023-04-28 08:26	Anonymous (not verified)	94.188.207.230	JD Transport	Limited Liability Company	24940 247th ave Princeton Iowa 52768	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-28	Jacob Dies	jacobdiestransport@gmail.com	Princeton	Scott	Iowa	Eric Dies	Karri Dies	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Dies	Jacobdiestransport@gmail.com	Self	Princeton	Scott	Iowa	Eric Dies	Karri Dies	Signed
1260	2022-08-16 11:30	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-16	Jacob Dreifurst	j_dreifurst@yahoo.com	Colona	Henry	Illinois	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed
1261	2022-08-16 11:30	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-16	Jacob Dreifurst	j_dreifurst@yahoo.com	Colona	Henry	Illinois	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed
2073	2024-03-04 15:51	Anonymous (not verified)	94.188.207.227	JACOB HANSON	Proprietorship	415 N 18TH ST ESTHERVILLE, IA 51334	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-04	JACOB HANSON	HANSONONEBOY@GMAIL.COM	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JACOB HANSON	HANSONONEBOY@GMAIL.COM	SELF	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1375	2022-11-18 10:21	Anonymous (not verified)	166.181.87.119	Heff Built Construction LLC	Limited Liability Company	1403 Kodiak Dr NW Cedar Rapids, IA 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-18	Jacob Heffernen	jheffernen@gmail.com	Cedar Rapids	Linn	IA	Kyle Reid	Amanda Frese	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Heffernen	jheffernen@gmail.com	N/A	Cedar Rapids	Linn	IA	Kyle Reid	Amanda Frese	Signed
1390	2022-12-12 10:27	Anonymous (not verified)	97.125.170.79	Norwalk Cleaning Servicesw	Limited Liability Company	520 W High Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-12	Jacob Hibbert	Maryhib@icloud.com	Norwalk	IA	United States	Kyle Grandstaff	Nicole Nichols	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Hibbert	maryhib@icloud.com	Self	Norwalk	Warren	United States	Kyle Grandstaff	Nicole Nichols	Signed
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
2026	2024-02-07 08:32	Anonymous (not verified)	94.188.205.169	Strong Fencing & Decking LLC	Limited Liability Company	343 59th Street Des Moines Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	Jacob James Strong	strongfencingdecking@gmail.com	Des Moines	Polk	Iowa	Paige Crowley	Jacob Waugh	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Strong	strongfencingdecking@gmail.com	Owner	Des Moines	Polk	Iowa	Paige Crowley	Jacob Waugh	Signed
1236	2022-08-01 20:06	Anonymous (not verified)	24.149.20.39	Jake's Insulation	Proprietorship	2020 Valley High Dr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-01	Jacob Ryan Smalley	jakersmalley@gmail.com	Cedar Falls	USA	Iowa	Emily Smalley	Ben Smalley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Ryan Smalley	jakersmalley@gmail.com	Owner	Cedar Falls	USA	Iowa	Emily Smalley	Ben Smalley	Signed
1345	2022-10-25 15:25	Anonymous (not verified)	166.181.82.169	Estling Junk and Garbage Removal	Limited Liability Company	660 West Main Street Apt.5	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-10-25	Jacob Steven Estling	JacobEstling1@gmail.com	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jacob Steven Estling	jacobestling1@gmail.com	Owner	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed
742	2021-11-11 15:14	Anonymous (not verified)	72.13.16.172	JACOB WESLEY JOHNSON	Proprietorship	1306 BAXTER AVENUE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-18	JACOB WESLEY JOHNSON	dave@allseasonstrucking.com	FAIRBANK	BUCHANAN	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	JACOB WESLEY JOHNSON	dave@allseasonstrucking.com	PRESIDENT	FAIRBANK	BUCHANAN	IA	Dave Neuwohner	BEN MOYER	Signed
1613	2023-04-27 13:57	Anonymous (not verified)	94.188.207.227	Jacob's Ladder Construction	Proprietorship	406 10th st Dallas Center Ia 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	Jacob Willis	jwillis924@gmail.com	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob A Willis	jwillis924@gmail.com	Owner	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed
1197	2022-07-11 08:35	Anonymous (not verified)	107.127.35.22	Leaf Filter	Limited Liability Partnership	3060 SE Grimes 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.	2022-07-11	Jacqueline Martínez	charamusca05erick@icloud.com	West Des Moines	United Stated	Iowa	Melvin Gomez	Martín Martínez	Signed	(1) The employer does not elect the employers’ liability coverage.	Leaf Filter	support@leafhome.com	Sub contractor	Grimes	United States	Iowa	Melvin Gomez	Martín Martínez	Signed
887	2022-02-03 14:05	Anonymous (not verified)	173.27.49.231	Jade Mallicoat coaching	Limited Liability Company	1318 se linn st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-03	Jade Mallicoat	jade.mallicoat@gmail.com	Boone	Boone	Iowa	Cord Anderson	Mike Anderson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jade mallicoat	jade.mallicoat@gmail.com	Myself	Boone	Boone	Iowa	Cord Anderson	Mike Anderson	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
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
2156	2024-04-16 17:00	Anonymous (not verified)	94.188.205.166	BONILLA STONE LLC	Limited Liability Company	3201 COLUMBIA ST DES MOINES, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-16	JAIRO JAVIER BONILLA SERRANO	jairobonilla509@gmail.com	DES MOINES	POLK	IOWA	ROCIO REYES	JOSE HERNANDEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	JAIRO JAVIER BONILLA SERRANO	jairobonilla509@gmail.com	SAME	DES MOINES	POLK	IOWA	ROCIO REYES	JOSE HERNANDEZ	Signed
250	2020-09-01 12:08	Anonymous (not verified)	207.191.193.167	Jairo Varela Roofing	Proprietorship	1681 Tofting Ave, Iowa City, IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Jairo Servellon Varela	olvinlanza06@gmail.com	Iowa City	Johnson	IA	Jessica Lopez	Anthony Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jairo Varela	olvinlanza06@gmail.com	Same	Iowa City	Johnson	IA	Jessica Lopez	Anthony Johnson	Signed
1966	2023-12-27 13:17	Anonymous (not verified)	94.188.205.177	Jake Borntreger	Proprietorship	50 Stone St Clermont, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-25	Jake Borntreger	darrele@ciains.biz	Clermont	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jake Borntreger	darrele@ciains.biz	self	Clermont	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed
544	2021-06-21 16:10	Anonymous (not verified)	97.125.169.60	Tenant Improvement Services, LLC	Limited Liability Company	3011 Justin Drive, Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-21	Jake Etter	jake@tenantimprovemetnsiowa.com	Polk City	Polk	Iowa	Ashley Overton	Aylah Etter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jake Etter	jake@tenantimprovementsiowa.com	Member	Polk City	Polk	Iowa	Ashley Overton	Aylah Etter	Signed
1378	2022-11-21 15:12	Anonymous (not verified)	136.34.59.85	Jake Jones	Proprietorship	203 9th Ave. Colona, Il 61241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-21	Jake Jones	jmjones807@gmail.com	Colona	Henry	Illinois	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Daniel Neal	Signed
1210	2022-07-18 08:15	Anonymous (not verified)	173.22.187.234	Cardinal Rule Handyman Services, LLC	Limited Liability Company	1304 E 10th St S, Newton, IA 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-18	James Andrew Dunlap	cardinarulehandyman@gmail.com	Newton	Jasper	Iowa	Jacinda Marie Dunlap	James Thornton Dunlap	Signed	(1) The employer does not elect the employers’ liability coverage.	James Andrew Dunlap	cardinalrulehandyman@gmail.com	I am the authorized agent	Newton	Jasper	Iowa	Jacinda Marie Dunlap	James Thornton Dunlap	Signed
2067	2024-02-29 16:58	Anonymous (not verified)	94.188.205.166	James Baker	Limited Liability Company	1510 E 1st Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-01	James Baker	jaykeribaker@yahoo.com	Indianola	Warren	IA	Keri Baker	Brenan Baker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Baker	jaykeribaker@yahoo.com	Self	Indianola	Warren	IA	Keri Baker	Brenan Baker	Signed
269	2020-09-23 09:18	Anonymous (not verified)	76.76.239.60	belilove company of Iowa Inc	Limited Liability Company	601 south 23rd street Fairfield Iowa 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-20	James Belilove	jimb@cec-waterjet.com	Fairfield	Jefferson	Iowa	James thompson	ellen bowen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Belilove	jimb@cec-waterjet.com	Owner and president	Fairfield	Jefferson	Iowa	James Thompson	Ellen Bowen	Signed
2121	2024-03-28 00:05	Anonymous (not verified)	94.188.205.176	James bunting	Limited Liability Company	6213 ridgewood meadows LN NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-28	James bunting	jbflooringtile@gmail.com	Cedar Rapids	Linn	Iowa	Codee Marie	Matt reynolds	Signed	(1) The employer does not elect the employers’ liability coverage.	James bunting	jbflooringtile@gmail.com	Myself	Cedar Rapids	Linn	Iowa	Codee Marie	Matt reynolds	Signed
1163	2022-06-23 09:17	Anonymous (not verified)	74.84.106.106	James Chitty	Proprietorship	307 2nd St Colo, Ia 50056	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-23	James Chitty	techsupport@smartind.com	Colo	Story	IA	Tina Owens	Kim Owens	Signed	(1) The employer does not elect the employers’ liability coverage.	James Chitty	techsupport@smartind.com	self	Colo	Story	IA	Tina Owens	Kim Owens	Signed
1494	2023-03-06 08:23	Anonymous (not verified)	94.188.207.223	James Douglas Clemons	Proprietorship	3807 SW 3rd st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	james clemons	james.clemons@grandview.edu	des moines	Iowa	United States	james clemons	james clemons	Signed	(1) The employer does not elect the employers’ liability coverage.	james clemons	james.clemons@grandview.edu	myself	des moines	Iowa	United States	james clemons	james clemons	Signed
761	2021-11-22 07:22	Anonymous (not verified)	73.211.163.27	James crockett	Limited Liability Company	417 easr st south Kewanee il 61443	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-22	James crockett	tattoojec@gmail.com	Kewanee il	Henery	Il	Tom mcintire	Colton english	Signed	(1) The employer does not elect the employers’ liability coverage.	Hog city construction	tattoojec@gmail.com	Self	Kewanee	Henery	Il	Tom mcintire	Colon english	Signed
608	2021-08-17 21:35	Anonymous (not verified)	50.82.65.174	33z Racing, LLC	Limited Liability Company	307 N Park Ave, New Sharon, IA. 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-17	James D VanderBeek	jvanderbeek@plbci.com	New Sharon	Mahaska	IA	Barbara M VanderBeek	Zackery James VanderBeek	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara M VanderBeek	bvanderbeek33z@gmail.com	Spouse	New Sharon	Mahaska	IA	James D VanderBeek	Zackery J VanderBeek	Signed
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
1250	2022-08-10 09:10	Anonymous (not verified)	75.162.190.54	Merit Paint Company	Proprietorship	1629 24th St, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-10	James Edward Simpson	jaybirdsimpson40@aol.com	Des Moines	Polk	Iowa	Regan Simpson	Hudson Simpson	Signed	(1) The employer does not elect the employers’ liability coverage.	James Simpson	jaybirdsimpson40@aol.com	Owner	Des Moines	Polk	Iowa	Regan Simpson	Hudson Simpson	Signed
2111	2024-03-21 14:28	Anonymous (not verified)	94.188.205.168	James Watson	Limited Liability Company	4708 71st Street Urbandale, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-24	James Edward watson	junior99@email.com	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Lantz	jason@lantzelite.com	Employer	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed
1199	2022-07-11 16:28	Anonymous (not verified)	166.222.225.181	Myriad Global Business Solutions	Proprietorship	8016 Brooks Loop	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-11	James Eugene Hasquet, III	Jay.Hasquet@Outlook.com	Spearfish	South Dakota	United States	Kent Orfield	Kyle Padget	Signed	(1) The employer does not elect the employers’ liability coverage.	James Eugene Hasquet, III	Jay.Hasquet@Outlook.com	Self	Spearfish	South Dakota	United States	Kent Orfield	Kyle Padget	Signed
107	2020-03-31 10:47	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-31	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed
462	2021-04-06 08:56	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven,IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-06	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
976	2022-03-15 10:44	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
1517	2023-03-14 09:06	Anonymous (not verified)	94.188.207.230	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-14	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
2141	2024-04-09 09:34	Anonymous (not verified)	94.188.205.177	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln Street Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-09	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed
2142	2024-04-09 09:39	Anonymous (not verified)	94.188.205.167	Bart Fuller & james Fuller DBA Fuller & Sons	Partnership	1302 Lincoln Street Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-09	James Fuller	goffins@ruthventel.com	Ruthven	Pal Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed
1212	2022-07-19 10:15	Anonymous (not verified)	174.209.40.210	James holmes	Proprietorship	866 40th Ave bettendorf IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-19	James holmes	jrholmes1958@gmail.com	Moline	Rock island	Il	Tiffani branham	Cody dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Leaffilter north llc	cdunbar@leaffilter.com	Install manager	Bettendorf	Scott	Ia	Cody dunbar	Tiffani branham	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
1222	2022-07-21 16:01	Anonymous (not verified)	66.129.208.246	James J Stallman	Proprietorship	190 BLUFF DR, Fairfax, IA 52228	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-21	James J Stallman	stallmanjim@aol.com	FAIRFAX	IA	United States	James J Stallman	James J Stallman	Signed	(1) The employer does not elect the employers’ liability coverage.	Lundahl, Hatt, Austad Tax Services Inc	NN@LHAtax.com	President	Marion	Linn	IA	James J Stallman	James J Stallman	Signed
719	2021-11-05 13:48	Anonymous (not verified)	174.198.66.202	James Johnson Ace Floor Guys	Proprietorship	521 29th st NE Cedar Rapids, Ia 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-13	James Johnson	acefloorguysia@gmail.com	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	James Johnson	acefloorguysia@gmail.com	Self Employed	Cedar Rapids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed
1618	2023-04-28 11:10	Anonymous (not verified)	94.188.205.167	Hunter Flying Service, LLC	Limited Liability Company	PO Box 215 Hunter, AR 72074	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-28	James Lynn Cary	hunterflying@att.net	Hunter	Woodruff	Arkansas	Karen Gifford	Jason White	Signed	(1) The employer does not elect the employers’ liability coverage.	James Lynn Cary	hunterflying@att.net	Self	Hunter	Woodruff	AR	Karen Gifford	Jason White	Signed
956	2022-03-08 13:56	Anonymous (not verified)	72.13.16.196	Naprstek Media LLC	Limited Liability Company	6505 Wellington Ln, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-08	James Naprstek	jimmy@kodiakcreative.com	Dubuque	Dubuque	Iowa	Trent Hanselmann	Jonathan O'Brien	Signed	(1) The employer does not elect the employers’ liability coverage.	Cheyenne Moseley	services@e.legazoom.com	Authorized Agent	Glendale	Los Angeles	CA	Trent Hanselmann	Jonathan O'Brien	Signed
303	2020-10-31 13:11	Anonymous (not verified)	173.17.230.149	Absolute Construction	Limited Liability Partnership	135 main street, Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-31	James Nelson	jamesnelson1983@gmail.com	Carlisle	Warren	Iowa	Joe Simpson	Alex Vanderbeek	Signed	(1) The employer does not elect the employers’ liability coverage.	James Nelson	jamesnelson1983@gmail.com	self	Carlisle	Warren	Iowa	Joe Simpson	Alex Vanderbeek	Signed
437	2021-03-16 18:31	Anonymous (not verified)	38.121.121.16	Thompsen Irrigation	Proprietorship	16086 Missouri Ave Crescent IA 51526	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-17	James R Thompsen	jthom76285@aol.com	Crescent	Pottawattamie	Iowa	Mike Harmon	Ilene Harmon	Signed	(1) The employer does not elect the employers’ liability coverage.	James R Thompsen	jthom76285@aol.com	self	Crescent	Pottawattamie	Iowa	Mike Harmon	Ilene Harmon	Signed
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
1666	2023-05-28 15:57	Anonymous (not verified)	94.188.207.223	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd 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.	2023-05-29	James Stock	jamese1053@gmail.com	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owner	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed
1668	2023-05-30 10:50	Anonymous (not verified)	94.188.207.230	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd 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.	2023-05-30	James Stock	jamese1053@gmail.com	Davenport	Scott	Iowa	Ronald Lang	Karen Stock	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owener	Davenport	Scott	Iowa	Ronald Lang	Karen Walker	Signed
1669	2023-05-30 11:05	Anonymous (not verified)	94.188.207.225	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd Davenport IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	James Stock	jamese1053@gmail.com	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owner	Davenport	Scott l	Ia	Ronald Lang	Karen Walker	Signed
1700	2023-06-22 14:53	Anonymous (not verified)	94.188.205.166	James Trotter	Limited Liability Company	1341 Cachelin Dr Carter Lake IA 51510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	James Trotter	trotterwizard@gmail.com	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed	(1) The employer does not elect the employers’ liability coverage.	James Trotter	trotterwizard@gmail.com	Self	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed
1701	2023-06-22 15:03	Anonymous (not verified)	94.188.207.228	Midwest Teleworks	Limited Liability Company	1341 Cachelin Dr Carter Lake IA 51510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	James Trotter	trotterwizard@gmail.com	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed	(1) The employer does not elect the employers’ liability coverage.	James Trotter	trotterwizard@gmail.com	Owner	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed
1076	2022-04-28 13:14	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	James Van Ginkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	self	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1914	2023-11-20 16:05	Anonymous (not verified)	94.188.207.227	Dark Horse Transport LLC	Limited Liability Company	301 Lincoln St, Brayton, IA 50042	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-20	James William Meese	bethany.dhtllc@gmail.com	Brayton	Audubon	Iowa	Hayley Meese-Cherry	Wyatt Jessen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Wiliam Meese	bethany.dhtllc@gmail.com	Owner	Brayton	Audubon	Iowa	Hayley Meese-Cherry	Wyatt Jessen	Signed
2062	2024-02-29 08:25	Anonymous (not verified)	94.188.205.169	Midwest Splicing LLC	Limited Liability Company	1803 N HALF BANK RD , Stringtown , OK 74569	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-29	James Xiong	midwestsplicing71@yahoo.com	Stringtown	OKLAHOMA	OKLAHOMA	Vang Pao Chang	Xia Vang	Signed	(1) The employer does not elect the employers’ liability coverage.	James Xiong	midwestsplicing71@yahoo.com	owner	STRINGTOWN	Oklahoma	Oklahoma	xia Vang	Vang Pao Chang	Signed
730	2021-11-08 14:58	Anonymous (not verified)	97.64.139.42	JZ INC	Limited Liability Company	2509 Ne 10th CT Grimes Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-08	James Zastrow	Zastrow74@gmail.com	Grimes	Iowa	United States	Kevan Wiggins	Jeremy Holmes	Signed	(1) The employer does not elect the employers’ liability coverage.	James Zastrow	zastrow74@gmail.com	Self	grimes	polk	iowa	Kevan Wiggins	Jeremy Holmes	Signed
1239	2022-08-02 10:53	Anonymous (not verified)	184.80.177.137	Jamie Ingle, DBA Jamie's Little Sunflowers	Proprietorship	7155 Columbus St - New Vienna, IA 52065	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-02	Jamie Ingle	jheims@english-insurance.com	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	dparsons@english-insurance.com	self	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
1774	2023-08-03 08:40	Anonymous (not verified)	94.188.205.168	J P Trucking, Inc.	Proprietorship	8768 White Tail Lane, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-03	Jamison Noel	jptrucking.jamison@gmail.com	Dubuque	DBQ	Iowa	Lindsay Noel	Andy Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Jamison Noel	jptrucking.jamison@gmail.com	Owner	Dubuque	Dubuque	Iowa	Lindsay Noel	Andy Kemp	Signed
1037	2022-04-07 08:16	Anonymous (not verified)	104.207.27.18	SION LUTHERAN CHURCH	Proprietorship	4525 FINCH AVE LAKE MILLS, IA 50450	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-07	JANE BRUNSVOLD	janebrunsvold@yahoo.com	LAKE MILLS	WINNEBAGO	IOWA	ANDREW STENSRUD	JILL FLUGUM	Signed	(1) The employer does not elect the employers’ liability coverage.	ANDREW STENSRUD	ANDREW@STENSRUDINSURANCE.COM	INSURANCE AGENT	LAKE MILLS	WINNEBAGO	IOWA	JANE BRUNSVOLD	JILL FLUGUM	Signed
122	2020-04-15 18:10	Anonymous (not verified)	136.37.174.39	Merge Midwest Engineering, LLC	Limited Liability Company	2668 W. Catalpa Street, Olathe, KS 66061	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-15	Janelle Marie Clayton	jclayton@mergemidwest.com	Olathe	Johnson	Kansas	David Jahner	Patrick McCartney	Signed	(1) The employer does not elect the employers’ liability coverage.	Janelle Marie Clayton	jclayton@mergemidwest.com	Self	Olathe	Johnson	Kansas	David Jahner	Patrick McCartney	Signed
475	2021-04-13 19:19	Anonymous (not verified)	173.31.147.225	COAST TO COAST MILLWRIGHT LLC	Limited Liability Company	2909 HWY 71 AND 9	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-05	JANIE CANTU	JOEL@WALKERINSURANCEIA.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	JANIE CANTU	janiecantu433@outlook.com	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
2183	2024-04-26 14:49	Anonymous (not verified)	94.188.205.168	Cory's Painting LLC	Limited Liability Company	Po Box 1161	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-01	Jared Birkenholz	jareddrewb@gmail.com	CEDAR FALLS	IA	United States	Colton Blue	Kari Houle	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	CEDAR FALLS	IA	United States	Colton Blue	Kari Houle	Signed
1682	2023-06-08 17:55	Anonymous (not verified)	94.188.205.174	Jared hoffman	Proprietorship	22429 250th st carroll IA 5140q	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-06	Jared Hoffman	jhoffman@live.com	Carroll	Carroll	Iowa	Jeff dentlinger	Brian babb	Signed	(1) The employer does not elect the employers’ liability coverage.	Jared Hoffman	jhoffman@live.com	Self	Carroll	Carroll	Iowa	Jeff dentlinger	Brian babb	Signed
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
2190	2024-04-29 09:28	Anonymous (not verified)	94.188.205.168	JOHNSON OHANA LLC	Limited Liability Company	145 GREENBRIER DR, BURLINGTON, IA 52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	JARED JOHNSON	KONAOHANAICE@GMAIL.COM	BURINGTON	DES MOINES	IOWA	MARCY KNAUSS	MATTHEW RINKER	Signed	(1) The employer does not elect the employers’ liability coverage.	MAGGIE JOHNSON	KONAOHANAICE@GMAIL.COM	PARTNER/SPOUSE	BURLINGTON	DES MOINES	IOWA	MARCY KNAUSS	MATTHEW RINKER	Signed
1815	2023-08-23 14:16	Anonymous (not verified)	94.188.207.228	JP Distribution, LLC	Limited Liability Company	3738 Pine Rdg NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-23	Jared Prelle	jpdist2014@gmail.com	North Liberty	IA	United States	Linda Stien	Dawn Franck	Signed	(1) The employer does not elect the employers’ liability coverage.	Jared Prelle	jpdist2014@gmail.com	Owner	North Liberty	Johnson	IA	Linda Stien	Dawn Franck	Signed
966	2022-03-11 10:04	Anonymous (not verified)	173.19.189.168	Steger Siding & Construction	Limited Liability Company	1020 25th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-11	Jared Steger	jared.steger@gmail.com	Marion	IA	United States	Jared Steger	Jared Steger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jared Steger	jared.steger@gmail.com	self	Marion	IA	United States	Jared Steger	Jared Steger	Signed
1127	2022-05-25 18:12	Anonymous (not verified)	216.51.235.160	Midwest Excavation & Trucking LLC	Limited Liability Company	21324 Spring Ave Clarksville, Ia 50670	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-25	Jared Stephen Ragsdale	Midwest.excavation.llc@gmail.com	Clarksville	Butler	Iowa	Dave Johnson	Patrick Lursen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jared Stephen Ragsdale	Midwest.excavation.llc@gmail.com	Myself	Clarksville	Butler	Iowa	Dave Johnson	Patrick Lursen	Signed
1192	2022-07-07 21:15	Anonymous (not verified)	174.242.226.74	Quelland Flooring	Limited Liability Company	P.O. Box 5, Van Meter, IA, 50261	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-07	Jared Tyler Quelland	Jquelland@gmail.com	Van Meter	IA	United States	Denise Walters	Madison Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jared Tyler Quelland	Jquelland@gmail.com	Self	Van Meter	IA	United States	Denise Walters	Madison Mileer	Signed
1562	2023-04-10 07:43	Anonymous (not verified)	94.188.205.174	JB Concrete and Construction	Limited Liability Company	306 1st Ave N.W Dayton Ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-10	JaredBerglund	jaredberglund71@gmail.com	Dayton	Webster	Iowa	Travis Sonksen	Chase Haman	Signed	(1) The employer does not elect the employers’ liability coverage.	JaredBerglund	jaredberglund71@gmail.com	Owner	Dayton	Webster	Iowa	Travis Sonksen	Chase Haman	Signed
579	2021-07-20 12:37	Anonymous (not verified)	166.205.124.133	M&M HOME IMPROVEMENT	Limited Liability Company	5406 28th Ave. Moline , IL 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-07-20	Jarred Alexander	bookkyddjay@gmail.com	Moline	USA	IL	Jacob Nagel	Jacob Nagel	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jarred Alexander	bookkyddjay@gmail.com	Same	Moline	USA	IL	Jacob Nagel	Jacob Nagel	Signed
401	2021-02-15 14:50	Anonymous (not verified)	66.188.136.150	Jarrod Wernimont	Proprietorship	24 Blackhawk Rd. Hanover, IL 61041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-12	Jarrod Wernimont	kschumacher@tricorinsurance.com	Hanover	Jo Daviess	IL	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Jarrod Wernimont	kschumacher@tricorinsurance.com	Same	Hanover	Jo Daviess	IL	Russell Masartis	Shuree Behr	Signed
1560	2023-04-07 11:47	Anonymous (not verified)	94.188.205.174	Art Deco Tile and Stone	Limited Liability Company	4615 94th Pl 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.	2023-04-07	Jasmin Musinovic	edin@artdecotileandstone.com	Urbandale	Polk	Iowa	Rick Wyant	Todd Wyant	Signed	(1) The employer does not elect the employers’ liability coverage.	Jasmin Musinovic	edin@artdecotileandstone.com	Self	Urbandale	Polk	Iowa	Rick Wyant	Todd Wyant	Signed
564	2021-07-08 13:33	Anonymous (not verified)	173.31.156.49	SS Docks	Limited Liability Company	P.O. Box 561 Okoboji IA 51355-0561	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-07-08	Jason Andrew Snow	snowjas75@gmail.com	Lake Park	Dickinson	IA	Amber Egesdal	Vickie Walters	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	SS Docks	snowjas75@gmail.com	Owner	Okoboji	Dickinson	IA	Amber Egesdal	Vickie Walters	Signed
955	2022-03-08 11:21	Anonymous (not verified)	166.181.80.171	JB Roofing & Home Repair	Limited Liability Company	453 South Street Kalona, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-08	Jason Boller	jbroofhr@gmail.com	Kalona	Washington	IA	Jodee Stransky	Christian Swartzentruber	Signed	(1) The employer does not elect the employers’ liability coverage.	Christian Swartzentruber	christian@fisherins.com	Insurance Agent	Kalona	Washington	IA	Jodee Stransky	Christian Swartzentruber	Signed
1128	2022-05-26 11:11	Anonymous (not verified)	174.213.144.187	Leaf Filter	Limited Liability Company	3060 se grimes blvd suite 100-300 Grimes iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-24	Jason charlet	jasonstreeservice2014@gmail.com	Minburn	Dallas	Iowa	Kami lillibridge	Dale charlet	Signed	(1) The employer does not elect the employers’ liability coverage.	N/a	jasoncharlet703@gmail.com	N/a	N/a	N/a	N/a	N/a	N/a	Signed
2195	2024-04-30 15:31	Anonymous (not verified)	94.188.205.166	Jason Cooper	Proprietorship	1181 Western Ave Stockton Iowa 52769	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-30	Jason cooper	jvcpainting88@gmail.com	Stockton	IA	United States	Violet minssen	Hope Bishop	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason cooper	jvcpainting88@gmail.com	Self	Stockton	IA	United States	Violet minssen	Hope Bishop	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
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
1902	2023-11-10 08:45	Anonymous (not verified)	94.188.207.226	Huff Construction LLC	Limited Liability Company	1309 Business 30 Sw, Mount Vernon, IA 52314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Jason Huff	huff.jasonm@gmail.com	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Huff	huff.jasonm@gmail.com	Owner	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed
1325	2022-10-02 20:07	Anonymous (not verified)	50.80.107.101	Hanson Custom Cleanup and Removal LLC	Limited Liability Company	1221 Fleur Dr. Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-02	Jason Jacob Hanson	jasonhanson1985@gmail.com	Waterloo	Blackhawk	Iowa	Cindy Shreve	Jacob Ring	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Hanson	jasonhanson1985@gmail.com	Self	Waterloo	Blackhawk	Iowa	Cindy Shreve	Jacob Ring	Signed
2030	2024-02-07 10:10	Anonymous (not verified)	94.188.207.227	Jason Jacobs	Proprietorship	115 West 7th St., Suite 1W, Spencer, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	Jason Jacobs	jason.jacobs@thrivent.com	Spencer	Clay	Iowa	Brad Bernardy	Emily Jacobs	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Jacobs	jason.jacobs@thrivent.com	Self	Spencer	Clay	Iowa	Brad Bernardy	Emily Jacobs	Signed
1413	2023-01-06 15:15	Anonymous (not verified)	199.120.121.97	Jason Gaul	Proprietorship	1088 Ridge Lane Harlan, IA 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-06	Jason Robert Gaul	gauljasonr@gmail.com	Harlan	Shelby	Iowa	Haley Leinen	Scott Leinen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Robert Gaul	gauljasonr@gmail.com	Self	Harlan	Shelby	Iowa	Haley Leinen	Scott Leinen	Signed
568	2021-07-09 09:26	Anonymous (not verified)	184.12.14.229	SS Docks LLC	Limited Liability Company	P.O. Box 561 Okoboji, IA 51355-0561	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-05-21	Jason Snow	k.kooima@q.com	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jason Snow - SS Docks LLC	k.kooima@q.com	Owner	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed
570	2021-07-09 16:42	Anonymous (not verified)	184.12.14.229	SS Docks LLC	Limited Liability Company	P.O. Box 561 Okoboji, IA 51355-0561	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-05-21	Jason Snow	kkooima@q.com	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jason Snow - SS Docks LLC	kkooima@q.com	Owner	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed
593	2021-08-03 12:29	Anonymous (not verified)	184.12.14.229	SS Docks LLC	Limited Liability Company	PO Box 561, Okoboji, IA 51355-0561	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-05-21	Jason Snow	k.kooima@q.com	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jason Snow - SS Docks LLC	k.kooima@q.com	Owner	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed
454	2021-03-26 09:46	Anonymous (not verified)	50.82.130.211	Jason Thoren	Proprietorship	104 1st Street NW, Tripoli, IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-04	Jason Thoren	cmins_re@mchsi.com	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Thoren	cmins_re@mchsi.com	Self	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	Signed
2101	2024-03-18 09:21	Anonymous (not verified)	94.188.205.166	Jason Tindle	Proprietorship	4103 1st St. Des Moines, Ia 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-18	Jason Tindle	jtconstruction93@yahoo.com	DES MOINES	IOWA	United States	Zach Miller	Nick Soma	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Tindle	jtconstruction93@yahoo.com	Myself	Same	Same	Same	Same	Same	Signed
1664	2023-05-25 13:18	Anonymous (not verified)	94.188.207.227	Jason Vreeman	Proprietorship	5571 170th St sibley Ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-25	Jason Vreeman	jvreeman21@gmail.com	Sibley	Osceola	IA	Katie Vreeman	Jerry vreeman	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Vreeman	jvreeman21@gmail.com	Self	Sibley	Osceola	IA	Katie Vreeman	Jerry vreeman	Signed
270	2020-09-25 10:14	Anonymous (not verified)	174.243.97.206	J Watts Electric	Limited Liability Company	615 E 2nd St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-25	Jason Watts	jason.watts@jwattselectric.com	Webster City	Hamilton	Iowa	Eli Ochoa	Cody Ewing	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Watts	jason.watts@jwattselectric.com	Self	Webster City	Hamilton	Iowa	Eli Ochoa	Cody Ewing	Signed
241	2020-08-23 16:10	Anonymous (not verified)	67.45.96.12	Wellik & Sons, LLC	Limited Liability Company	1770 HWY 18, Garner, IA 50438	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-23	Jason Yon Juenger	j420money@yahoo.com	Garner	Hancock	Iowa	Joshua P Wellik	Ashley S Wellik	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Paul Wellik	wellikandsons@gmail.com	subcontractor	Garner	Hancock	Iowa	Joshua Paul Wellik	Ashley S Wellik	Signed
1692	2023-06-15 15:20	Anonymous (not verified)	94.188.207.228	Javier Rodriguez	Proprietorship	1512 18th St Des Moines, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-14	Javier A Rodriguez	R.Javier14@gmail.com	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier A Rodriguez	R.Javier14@gmail.com	self	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed
1120	2022-05-19 09:49	Anonymous (not verified)	65.125.92.130	JG Landscaping, LLC	Limited Liability Company	317 E 23rd St. Des Moines, IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-19	Javier Alexander Guzman	alexguz76@outlook.com	Des Moines	Polk	IA	Brenda Reedy	Chad Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier Alexander Guzman	alexguz76@outlook.com	Self	Des Moines	Polk	IA	Brenda Reedy	Chad Smith	Signed
2196	2024-05-01 09:18	Anonymous (not verified)	94.188.207.230	Penaloza Stone LLC	Limited Liability Company	1530 8th St Des Moines IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-01	Javier Marcial Penaloza	javiermarcial.jmp@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier Marcial Penaloza	javiermarcial.jmp@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
470	2021-04-13 09:34	Anonymous (not verified)	173.21.135.56	JNZ Recruiting LLC	Limited Liability Company	703 Washington St. Williamsburg, IA 52361	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-04-07	Javier Nevarez	amanda@burginsuranceagency.com	Williamsburg	IA	IA	Amanda Clubb	Bradley Schaefer	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Javier Nevarez	amanda@burginsuranceagency.com	Self	Williamsburg	Iowa	Iowa	Amanda Clubb	Bradley Schaefer	Signed
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
1573	2023-04-14 13:43	Anonymous (not verified)	94.188.205.167	Jaxon Kressley	Proprietorship	954 Boston Way, #12, Corralville, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-14	Jaxon Kressley	jaxon@optionsexteriors.com	Corralville	Johnson	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaxon Kressley	jaxon@optionsexteriors.com	Owner/Self	Corralville	Johnson	Iowa	Charlotte Rasmussen	Austin Miller	Signed
124	2020-04-16 12:07	Anonymous (not verified)	96.3.180.122	Gold Rush, LLC	Limited Liability Company	1395 130TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-16	Jay Christopher Morrow	jcmorrow2@hotmail.com	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed	(1) The employer does not elect the employers’ liability coverage.	Gold Rush, LLC	jcmorrow2@gmail.com	Self	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed
406	2021-02-18 10:41	Anonymous (not verified)	165.225.61.119	Romeo Painitng	Proprietorship	7 Waverly Dr Rock Island, IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-18	Jay Romeo	jay.romeo12@yahoo.com	Rock Island	Rock Island	IL	Seth Rowland	Ryan Myers	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Romeo	jay.romeo12@yahoo.com	Self	Rock island	Rock Island	IL	Seth Rowland	Ryan Myers	Signed
725	2021-11-05 14:32	Anonymous (not verified)	174.198.66.202	Jay Schulte	Proprietorship	7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	Jay Schulte	schultejay@Hotmail.com	Cedar Rapids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Schulte	schultejay@hotmail.com	Self Employed	Cedar Rapids	Linn	Ia	Sarah Coberley	Heather Howell	Signed
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
1931	2023-12-01 18:01	Anonymous (not verified)	94.188.207.225	Jay Wang	Limited Liability Company	16672 Verona Hills Dr, Clive IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Jay Wang	jaywang@wasabidsm.com	Clive	US	IA	WenHui chen	Yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	Jaywang@wasabidsm.com	Self	Clive	US	IA	WenHui Chen	Yingna Zheng	Signed
1935	2023-12-02 18:34	Anonymous (not verified)	94.188.207.229	Wasabi Johnston LLC	Limited Liability Company	8184 Birchwood Ct, Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-02	Jay Wang	jaywang@wasabidsm.com	Clive	Dallas	IA	Engjin zheng	yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	self	Clive	Dallas	IA	Wenhui Cheng	Enjing Zheng	Signed
1984	2024-01-15 17:33	Anonymous (not verified)	94.188.207.227	Jay Wang	Limited Liability Company	8481 Birchwood Ct, Johnston	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-15	Jay Wang	jaywang@wasabidsm.com	Clive	US	IA	Yingna Zheng	Qiaoqiao Li	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	Self	Clive	US	IA	Yingna Zheng	Qiaoqiao Li	Signed
2003	2024-01-28 12:38	Anonymous (not verified)	94.188.205.169	Wasabi Urbandale LLC	Limited Liability Company	2301 Rocklyn 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.	2024-01-01	Jay Wang	jaywang@wasabidsm.com	Clive	Dallas	IA	Ajdin Nadarich	Jeremy Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	Self	Clive	Dallas	IA	Lisa Lee	Yingna Zheng	Signed
1020	2022-03-29 16:53	Anonymous (not verified)	207.32.60.144	J.A. Dahlhauser, Ltd.	Proprietorship	1741 Hwy. 7	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Jaylin A. Dahlhauser	jaydahlhauser@gmail.com	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaylin A. DAhlhauser	jaydahlhauser@gmail.com	Owner	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed
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
869	2022-01-28 15:28	Anonymous (not verified)	63.229.189.35	Jones Painting	Proprietorship	PO box 523, Okoboji, IA 51355	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-28	JD Jones	abigail@rickmilesartisans.com	Okoboji	Dickinson	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	JD Jones	abigail@rickmilesartisans.com	Self	Okoboji	Dickinson	Iowa	Abigail Miles	Alex Miles	Signed
1107	2022-05-16 15:28	Anonymous (not verified)	64.33.230.163	hangar 8 spray service	Limited Liability Company	1626 airport dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-16	jed douglas hansen	hangar.8@hotmail.com	Clark	South Dakota	United States	jed douglas hansen	jed douglas hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	jed douglas hansen	hangar.8@hotmail.com	contract	Clark	South Dakota	United States	Jed Hansen	Jed Hansen	Signed
1110	2022-05-17 11:17	Anonymous (not verified)	64.33.230.163	Jed Hansen	Proprietorship	1626 Airport Dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-17	Jed Douglas Hansen	hangar.8@hotmail.com	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jed Hansen	hangar.8@hotmail.com	Proprietor	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed
1111	2022-05-17 11:18	Anonymous (not verified)	64.33.230.163	Jed Hansen	Proprietorship	1626 Airport Dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-17	Jed Douglas Hansen	hangar.8@hotmail.com	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jed Hansen	hangar.8@hotmail.com	Proprietor	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed
2216	2024-05-09 11:51	Anonymous (not verified)	94.188.207.229	Imhoff Innovations LLC	Limited Liability Company	108 Cherry Lane Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-09	Jediah Imhoff	jedimhoff@gmail.com	Riverside	IA	United States	Jordan Nisiewicz	Jordan Lyod	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Johnson	MO	Jordan Lyod	Jediah Imhoff	Signed
1506	2023-03-08 15:12	Anonymous (not verified)	94.188.207.226	Heritage Towing LLC	Limited Liability Company	404 Sherman Ave. Ackley Iowa 50601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-08	Jeff Brass	heritagemotors17@yahoo.com	Ackley	Hardin	Iowa	Joellen Reynolds	Linzie Morris	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeff Brass	hertiagemotors17@yahoo.com	Member of LLC	Ackley	Hardin	Iowa	JoEllen Reynolds	Linzie Morris	Signed
512	2021-05-11 13:12	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	JEFF CACEK	JEFF@RUTHVENROCKS.COM	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JEFF CACEK	joel@walkerinsuranceia.com	MEMBER	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
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
336	2020-12-11 11:55	Anonymous (not verified)	173.16.197.72	A Metro Snow Removal And Lawn Care	Limited Liability Company	6436 Washington Ave Windsor Heights, Iowa 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-11	Jeff Lamp Sr.	jeff.lamp79@gmail.com	Windsor Height	Polk	Iowa	Rick Brown	Jill Fresh	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeff Lamp Sr.	Jeff.lamp79@gmail.com	Owner	Windsor Heights	Polk	Iowa	Rick Brown	Jill Fresh	Signed
2092	2024-03-13 12:55	Anonymous (not verified)	94.188.205.175	Banker's Lock and Safe	Proprietorship	1914 Porter 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.	2024-03-13	Jeff Losee	bankerslockandsafe@yahoo.com	Des Moines	Polk	IA	Jennifer D Losee	Kendra D Losee	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeff Losee	bankerslockandsafe@yahoo.com	Owner	Des Moines Iowa	Polk	IA	Jennifer D Losee	Kendra D Losee	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
311	2020-11-10 10:42	Anonymous (not verified)	75.162.206.98	Menz Construction, LCC	Limited Liability Company	304 SW Clark Lane, Grimes, Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-10	Jeff Menz	construction.menz@gmail.com	Grimes	Polk	Iowa	Janelle Menz	Barb Menz	Signed	(1) The employer does not elect the employers’ liability coverage.	David Finneseth	david.finneseth@fbfs.com	Agent	Perry	Dallas	Iowa	Janelle Menz	Barb Menz	Signed
1486	2023-02-26 17:53	Anonymous (not verified)	94.188.205.177	TURNER LAWN CARE	Limited Liability Company	16493 185th Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-27	JEFF TURNER	jscturner2626@gmail.com	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed	(1) The employer does not elect the employers’ liability coverage.	SHARON RENEE TURNER	jscturner2626@gmail.com	wife	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed
1929	2023-11-30 10:46	Anonymous (not verified)	94.188.207.225	White Masonry, Inc.	Proprietorship	15141 Bluff Trl., Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-30	Jeff White	whitemasonry1979@hotmail.com	Carlisle	IA	IA	Cathleen Marie White	Sam Jeffrey White	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Dean White	WHITEMASONRY1979@HOTMAIL.COM	Self	CARLISLE	ia	ia	Cathleen Marie White	Sam Jeffrey White	Signed
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
440	2021-03-18 08:11	Anonymous (not verified)	66.188.136.150	Jeffrey Gardner	Proprietorship	3020 W 1st St., Davenport, IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-17	Jeffrey Gardner	kschumacher@tricorinsurance.com	Davenport	Polk	IA	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Gardner	kschumacher@tricorinsurance.com	Same	Davenport	Polk	IA	Russell Masartis	Shuree Behr	Signed
344	2020-12-28 11:31	Anonymous (not verified)	173.31.147.225	JEFFREY GOETZINGER	Proprietorship	2112 ITHACA AVE SPIRIT LAKE IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-22	JEFFREY GOETZINGER	WALKERINSURANCE@MCHSI.COM	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JEFFREY GOETZINGER	WALKERINSURANCE@MCHSI.COM	SELF	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
586	2021-07-26 08:37	Anonymous (not verified)	71.7.62.131	Jeffrey Knoot	Proprietorship	1251 Illinois Dr. Knoxville IA, 50138-8862	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Jeffrey Jon Knoot	opsisdental@gmail.com	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Jon Knoot	opsisdental@gmail.com	self	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	Signed
2013	2024-01-31 15:14	Anonymous (not verified)	94.188.205.167	Aspen Ridge LLC	Limited Liability Company	1404 G Ave Marengo, IA 52301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-10	Jeffrey McKusker	jeff@mckuskerelectric.com	Marengo	Iowa	Iowa	Karly Kovar	Jacob McKusker	Signed	(1) The employer does not elect the employers’ liability coverage.	Lori McKusker	jeff@mckuskerelectric.com	Spouse	Mead	Weld	Colorado	Karly Kovar	Jacob McKusker	Signed
412	2021-02-23 14:23	Anonymous (not verified)	205.185.135.176	Jeffrey Meyer	Proprietorship	118 1st St SE New Albin IA 52160	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-23	Jeffrey Meyer	meyertimberservices@gmail.com	New Albin	Allamakee	Iowa	Michael Klug	Kayla Snitker	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Klug	mike@aibme.com	Insurance Agent	Caledonia	Houston	Minnesota	Jeffrey Meyer	Kayla Snitker	Signed
67	2020-02-19 10:16	Anonymous (not verified)	198.167.182.164	AWF579 LLC	Limited Liability Company	13 Lynden Dr NE, Iowa City, IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Managing Member	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
205	2020-07-15 14:19	Anonymous (not verified)	108.209.12.64	Sequoia integrative Medical Services	Limited Liability Company	1746 Paul Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-15	Jennifer Christine VandenHeuvel	jvandenheuvel@att.net	Kaukauna	WI	United States	David VandenHeuvel	Pam Leplavy	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Christine VandenHeuvel	jvandenheuvel@att.net	Owner	Kaukauna	WI	United States	David VandenHeuvel	Pam Leplavy	Signed
882	2022-02-02 11:09	Anonymous (not verified)	67.55.205.135	Tree & Forestry Equipment	Partnership	201 Deer Haven St., Polk City, IA 50226	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-02	Jennifer Hicks	jennifer@treeandforestry.com	Gowrie	Webster	Iowa	Chad Hicks	Caden Konecne	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Hicks	jennifer@treeandforestry.com	self	Gowrie	Webster	Iowa	Chad Hicks	Caden Konecne	Signed
1680	2023-06-06 12:08	Anonymous (not verified)	94.188.205.168	Sipac Drywall	Proprietorship	1130 Columbia 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.	2023-06-06	Jennifer Sipac	jenniferyoung164@gmail.com	Waterloo	Black Hawk	Iowa	Augie Ferguson	Wendy Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Sipac	jenniferyoung164@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Augie Ferguson	Wendy Phillips	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
328	2020-11-26 12:28	Anonymous (not verified)	174.198.82.38	Duke millwright doing business as duke & sons	Limited Liability Company	3264 e Payton ave Des Moines iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-11-26	Jeremiah duke	jpduke24.7.365@gmail.com	Des Moines	Polk county	Iowa	Daniel Patrick Hemann	Nikki Marie Harvey	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Diana duke	dukemillwright@gmail.com	Self	Des Moines	Polk	Iowa	Nikki Marie Harvey	Daniel Patrick Hemann	Signed
722	2021-11-05 14:07	Anonymous (not verified)	209.252.172.87	Jeremiah Lunsford	Proprietorship	624 Carroll Dr SE, Cedar Rapids, IA 52403	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-10	Jeremiah Lundsford	jjaylunsford@gmail.com	Cedar Paids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah Lunsford	jjaylunsford@gmail.com	Self Employed	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed
1071	2022-04-26 15:31	Anonymous (not verified)	63.152.69.47	Black squirrel siding llc	Limited Liability Company	1512 n 1st Ave apt c203s coralville,ia52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Jeremiah Petsche	jpetsche44@gmail.com	Coralville	Johnson	Iowa	Jessica schimf	Karl schimf	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah petsche	jpetsche44@gmail.com	Myself	Coralville	Johnson	Iowa	Jessica schimf	Karl schimf	Signed
1954	2023-12-13 13:51	Anonymous (not verified)	94.188.207.227	Beeson Trucking LLC	Limited Liability Company	219 Tilden St Kingsley IA 51028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-13	Jeremy Beeson	jeremy4k78@yahoo.com	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy Beeson	jeremy4k78@yahoo.com	Self	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed
499	2021-04-28 08:05	Anonymous (not verified)	167.142.98.81	Bents Consulting LLC	Limited Liability Company	2147 160th Street Boone Iowa 50036	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-28	Jeremy D Bents	help@bentsconsulting.com	Boone	Boone	Iowa	Derek Hanson	Bob Clements	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy D Bents	help@bentsconsulting.com	Owner	Boone	Boone	Iowa	Derek Hanson	Bob Clements	Signed
1709	2023-06-26 14:55	Anonymous (not verified)	94.188.205.177	Jeremy Pledge	Proprietorship	3310 East Washington Street, Iowa City, IA 52245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-26	Jeremy Pledge	worknoplay8@gmail.com	Iowa City, IA	Johnson County	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Woods	Jordan Loyd	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
2185	2024-04-26 16:46	Anonymous (not verified)	94.188.205.166	Jerilyn Horn Kitchen and Bath Design Co.	Proprietorship	413 Jefferson St., Burlington, IA 52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-26	Jerilyn Michelle Horn	designsbyjerilyn@gmail.com	Mt. Pleasant	Henry	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerilyn Michelle Horn	designsbyjerilyn@gmail.com	owner	Mt. Pleasant	Henry	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed
304	2020-10-31 13:23	Anonymous (not verified)	173.17.230.149	Jerome Jones	Proprietorship	5203 Douglas Avenue, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-31	Jerome Jones	jeromepops1@gmail.com	Des Moines	Polk	IA	Joe Simpson	James Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerome Jones	jeromepops1@gmail.com	self	Des Moines	Polk	IA	Joe Simpson	James Nelson	Signed
258	2020-09-15 13:14	Anonymous (not verified)	50.83.182.140	Moyer Painting	Proprietorship	934 Norwood Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	jerome Moyer	moyer_painting@live.com	Norwalk	IA	United States	Sally Moyer	Adam Adams	Signed	(1) The employer does not elect the employers’ liability coverage.	jerome b moyer	moyer_painting@live.com	Self	norwalk	IA	United States	sally moyer	Adam Adams	Signed
21	2020-01-01 18:16	Anonymous (not verified)	72.35.186.80	Jerry Arnold	Proprietorship	1426 25th St, Humeston, IA 50123	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Jerry Arnold	LLArnold62@gmail.com	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Arnold	LLArnold62@gmail.com	Self	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed
1353	2022-10-31 21:35	Anonymous (not verified)	50.82.84.225	Jerry Bassett	Proprietorship	108 NE 22 Cr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-31	Jerry Bassett	JerryDebBassett@aol.com	GRIMES	IA	United States	Deb Bassett	Jerry Bassett	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Bassett	JerryDebBassett@aol.com	Self	Grimes	Polk	Iowa	Deb Bassett	Jerry Bassett	Signed
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
1054	2022-04-15 15:05	Anonymous (not verified)	173.23.251.188	Integrity Design & Development, LLC	Limited Liability Company	810 NW Logan St Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-15	Jerry Houk	integrity.design.development@gmail.com	Ankeny	Polk	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Integrity Design & Development, LLC	integrity.design.development@gmail.com	owner	Ankeny	Polk	Iowa	Tara Murphy	Mike Ryerson	Signed
2193	2024-04-30 11:37	Anonymous (not verified)	94.188.205.168	Hausman Dozing LLC	Limited Liability Company	24860 230th St Carroll, Iowa 51401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-30	Jess Jonathan Hausman	hausmandozing@gmail.com	Carroll	Carroll	IOWA	Jeff Dentlinger	Lauren Brauckman	Signed	(1) The employer does not elect the employers’ liability coverage.	Jess Hausman	hausmandozing@gmail.com	Owner	Carroll	Carroll	IOWA	Jeff Dentlinger	Lauren Brauckman	Signed
2162	2024-04-18 19:25	Anonymous (not verified)	94.188.205.177	Escobar Enterprises, LLC	Limited Liability Company	125 East Broad Street, Des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-18	Jesse Escobar	jesse@escobar-enterprises.com	Des Moines	Polk	Iowa	Rene Mauricio Martinez	Jessa Caitlin Marfal	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Escobar	jesse@escobar-enterprises.com	owner	Des Moines	Polk	Iowa	Rene Mauricio Martinez	Jessa Caitlin Marfal	Signed
945	2022-03-04 10:15	Anonymous (not verified)	97.125.39.88	Solid Solutions Caulking LLC.	Limited Liability Company	1011 N. Ankeny Blvd P.O. Box 216. Ankeny Ia. 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-04	Jesse Guilford	sscaulking@yahoo.com	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed	(1) The employer does not elect the employers’ liability coverage.	Jade Guilford	sscaulking@yahoo.com	Secratary	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed
1419	2023-01-12 09:27	Anonymous (not verified)	71.34.173.44	Solid Solutions Caulking LLC.	Limited Liability Company	1011 N. Ankeny BLVD Po Box 216 Ankeny IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Jesse Guilford	sscaulking@yahoo.com	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Guilford	sscaulking@yahoo.com	Self	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed
1397	2022-12-21 14:05	Anonymous (not verified)	50.81.162.60	Jesse Iseminger	Proprietorship	3117 e 40th ct, Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-21	Jesse Iseminger	Jesseiseminger@gmail.com	Des Moines	Polk	Iowa	Shelly Johns	Brad Weikert	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Iseminger	Jesseiseminger@gmail.com	Self	Des Moines	Iowa	Iowa	Shelly Johns	Brad Weikert	Signed
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
1124	2022-05-25 06:32	Anonymous (not verified)	69.77.219.67	J&T Dairy Cattle Company	Proprietorship	1524 290th St. Inwood IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-25	Jesse T VanDeStroet	inwoodfeeders@gmail.com	Inwood	Lyon	IA	Josh Tommeraus	Nathan Van Der Wilt	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse T VanDeStroet	inwoodfeeders@gmail.com	Owner	Inwood	Lyon	Iowa	Josh Tommeraus	Nathan Van Der WIlt	Signed
85	2020-03-09 08:17	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-05	Jessi Kettenacker	jessi@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessi Kettenacker	jessi@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
315	2020-11-13 10:48	Anonymous (not verified)	66.188.136.150	Jessie Spurlin	Proprietorship	58977 Al Hwy 77, Talladega, AL 35160	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-11	Jessie Spurlin	kschumacher@tricorinsurance.com	Talladega	Talladega	AL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessie Spurlin	kschumacher@tricorinsurance.com	Same	Talledaga	Talledaga	AL	Russell Masartis	Nancy Wortley	Signed
1485	2023-02-25 18:14	Anonymous (not verified)	94.188.205.177	J&V painting	Limited Liability Company	4759 woodland AV #56 West Des moines IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-25	Jessika Romero	jony.bel.vla@gmail.com	West Des Moines	Polk	Ia	Samir rahmanovic	Samir rahmanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessika Romero	jony.bel.vla@gmail.com	Self	West Des Moines	Polk	IA	Samir Rahmanovic	SAMIR RAHMANOVIC	Signed
261	2020-09-17 15:52	Anonymous (not verified)	65.127.131.118	Jesus Adrian Martinez	Proprietorship	1517 Searle St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-17	Jesus Adrian Martinez	adrianmartinezventura21@gmail.com	Des Moines	Polk	Iowa	Brian Pruitt	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesus Adrian Martinez	adrianmarinezventura21@gmail.com	self	Des Moines	Polk	Iowa	Brian Pruitt	Martin Pinon	Signed
1608	2023-04-26 11:51	Anonymous (not verified)	94.188.205.167	Jesus Lozano	Proprietorship	1334 E 16th st Des Moines Iowa 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-26	Jesus Lozano	Jesuslozano0086@icloud.com	Des Moines	Polk	Iowa	Sheanah Wright	Derek Mullins	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesus Lozano	Jesuslozano0086@icloud.com	Owner	Des Moines	Polk	Iowa	Sheanah Wright	Derek Mullins	Signed
960	2022-03-09 11:13	Anonymous (not verified)	65.144.174.26	Jesus Munoz	Proprietorship	401 6th Ave Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-09	Jesus Munoz	jesus131805@gmail.com	Coralville	Johnson	Iowa	Juan Cruz	Marlon Cruz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesus Munoz	jesus131805@gmail.com	Self	Coralville	Johnson	Iowa	Juan Cruz	Marlon Cruz	Signed
1006	2022-03-25 10:26	Anonymous (not verified)	107.115.239.110	Jesus ojeda	Limited Liability Company	866 40th Ave Bettendorf IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-25	Jesus Ojeda	jesusojeda386@gmail.com	2112 20 1/2 Ave Rock Island 61201	United States	Illinois	Cody Dunbar	Tiffani branham	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	cdunbar@leaffilter.com	Install manager	866 40th Ave Bettendorf IA 52722	United States	Iowa	Jordan Nisiewicz	Tiffani Branham	Signed
56	2020-02-07 15:17	Anonymous (not verified)	204.153.176.73	J*M Fuels, LLC	Limited Liability Company	600 W Bremer Avenue, Waverly IA 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-07	Jim Johnson	mattjohnson7555@gmail.com	Jackson TWP	Butler	Iowa	Ty Burke	Lori Frerichs	Signed	(1) The employer does not elect the employers’ liability coverage.	Ty Burke	tburke@acceladvantage.com	Agent	Waverly	IA	United States	Tony Pollastrini	Lori Frerichs	Signed

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