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:
281	2020-10-20 08:58	Anonymous (not verified)	136.37.174.39	Merge Midwest Engineering, LLC	Limited Liability Company	2668 W Catalpa Street, Olathe, KS 66061	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-20	Michael Lee Baer	lbaer@mergemidwest.com	Louisburg	Miami	Kansas	Heather Lee Baer	Ami Bowes	Signed	(1) The employer does not elect the employers’ liability coverage.	Janelle Marie Clayton	jclayton@mergemidwest.com	Self	Olathe	Johnson	Kansas	Patrick McCartney	David Jahner	Signed
691	2021-10-26 14:54	Anonymous (not verified)	65.144.174.26	Alfonso Montoya	Proprietorship	2114 Nw Maple St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Alfonso Montoya	fonzflooring@gmail.com	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Alfonso Montoya	fonzflooring@gmail.com	Owner	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed
1533	2023-03-25 10:24	Anonymous (not verified)	94.188.207.226	Doug Uridil	Proprietorship	616 16th Street NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-22	Doug Uridil	douguridil@gmail.com	Cedar Rapids	United States	IOWA	Heidi Vincent	Molly Coffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Uridil	douguridil@gmail.com	Self	Cedar Rapids	United status	IOWA	Heidi Vincent	Molly Kaufman	Signed
1061	2022-04-19 19:30	Anonymous (not verified)	172.58.83.52	Rodolfo Perez	Proprietorship	3420 E 12th 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.	2022-04-19	Rodolfo Perez	Elgordo0738@gmail.com	Des Moines	Polk	Iowa	Henry santos	Larry ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Lantz	Info@lantzelite.com	Self employed no workers	Urbandale	Polk	Iowa	Henry santos	Larry ramos	Signed
1122	2022-05-21 12:19	Anonymous (not verified)	173.24.108.210	Daly Building Service,LLc	Limited Liability Company	409 Dammann dr. Eldridge IA, 52748	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-21	Noah Daly	Noahdalyubs@gmail.com	Eldridge	Scott County	Iowa	Holly Roberts	Corinna Daly	Signed	(1) The employer does not elect the employers’ liability coverage.	Derick Perry	biglakellc@outlook.com	Liability policy agent	Eldridge	Scott county	Iowa	Holly roberts	Corinna Daly	Signed
11	2019-12-17 19:46	Anonymous (not verified)	50.83.188.192	B & B Construction	Proprietorship	2463 93rd Avenue, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-17	Louis I. Maxwell	brockbrooke2463@yahoo.com	Norwalk	IA	United States	Hope Winegardner	Yvonne Ginther	Signed	(1) The employer does not elect the employers’ liability coverage.	Louis Maxwell	brockbrooke2463@yahoo.com	Owner	Norwalk	IA	United States	Hope Winegardner	Yvonne Ginther	Signed
12	2019-12-17 19:54	Anonymous (not verified)	50.83.188.192	B & B Construction	Proprietorship	2463 93rd Avenue Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-17	Brock A Maxwell	brock246393@gmail.com	Des Moines	IA	United States	Hope Winegardner	Yvonne Ginther	Signed	(1) The employer does not elect the employers’ liability coverage.	Brock A Maxwell	brock246393@gmail.com	Owner	Des Moines	POlK	Iowa	Yvonne Ginther	Hope Winegardner	Signed
754	2021-11-19 08:27	Anonymous (not verified)	65.144.174.26	miguel albino	Proprietorship	8760 cody dr. unit 107 west des moines	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-19	miguel albino	albino.miguel627@gmail.com	west des moines	united states	iowa	humbeto albino	johnothan albino	Signed	(1) The employer does not elect the employers’ liability coverage.	miguel albino	albino.miguel627@gmail.com	self	west des moines	united states	iowa	humberto albino	johnothan	Signed
1864	2023-10-09 09:52	Anonymous (not verified)	94.188.207.223	Admiral Staffing Inc	Limited Liability Company	580 8th Ave, 15th Floor, New York NY 10018	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-09	Rezwan Rafeek	ray@admiralstaffinginc.com	23 Catalpa Lane	Valley Stream	NY	Ikbal Sherif	Salim Balee	Signed	(1) The employer does not elect the employers’ liability coverage.	Shafi Rafeek	shafi@admiralstaffinginc.com	Office Manager	New York	NY	United States	Ikbal Sherif	Salin Balee	Signed
1150	2022-06-10 16:14	Anonymous (not verified)	173.29.125.38	Vernon Tim McClain	Limited Liability Company	2717 Thompson ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-10	Vernon Tim McClain	mcclainlawn@gmail.com	Des Moines	POlk	Iowa	Ilisha Carter	Earl Warren Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	vernon mcclain	mcclainlawn@gmail.com	business owner	des moines	polk	iowa	Ilisha Carter	Earl Warren Jr.	Signed
1750	2023-07-17 11:00	Anonymous (not verified)	94.188.205.166	Mario Flores	Proprietorship	2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-22	Mario Zubia Flores	deb@piciowa.com	Des Moiines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed	(1) The employer does not elect the employers’ liability coverage.	Mario Zubia Flores	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed
1751	2023-07-17 11:00	Anonymous (not verified)	94.188.205.166	Mario Flores	Proprietorship	2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-22	Mario Zubia Flores	deb@piciowa.com	Des Moiines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed	(1) The employer does not elect the employers’ liability coverage.	Mario Zubia Flores	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed
1749	2023-07-17 10:52	Anonymous (not verified)	94.188.205.175	Zenon Loreto	Proprietorship	1324 E 29th St Des Moines, IOwa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-17	Zenon Loreto	deb@piciowa.com	Des Moines	Polk	Iowa	Inspro in 2019	Inspro in 2019	Signed	(1) The employer does not elect the employers’ liability coverage.	Zenon Loreto	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro in 2019	Inspro in 2019	Signed
246	2020-08-25 15:36	Anonymous (not verified)	97.125.173.2	MPT plumbing	Limited Liability Company	4616 147th 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.	2020-08-25	justin lee tigges	tplumbing3@aol.com	urbandale	dallas	iowa	insurance is a scam	I would get a different issurance company	Signed	(1) The employer does not elect the employers’ liability coverage.	grinnell mutual	lori@grinnellmutual.com	insurance agent	i dont know	I don't know	iowa	what a pain in the ass	This makes no sense	Signed
1058	2022-04-19 13:19	Anonymous (not verified)	50.83.154.192	Property Maintenance Services of Iowa LLC	Limited Liability Company	PO Box 166 Low Moor IA 52757	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	Frederick Stewart	curlyfry42000@yahoo.com	LOW MOOR	IA	United States	Irene R Stewart	Derek S Jensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Frederick Lee Stewart	zombiesby2012@gmail.com	Owner	Clinton	IA	United States	Irene R Stewart	Derek S Jensen	Signed
467	2021-04-10 12:21	Anonymous (not verified)	24.252.54.168	Dave and Nancy Preucil Inc.	Proprietorship	13585 Clearview Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-10	Domenico Zurini II	davesspeedwaydz@gmail.com	Council Bluffs	IA	United States	Irven Saar II	Jeffrey Hanke	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbi Zurini	bzurini@gmail.com	Wife	Council Bluffs	IA	United States	Irven Saar II	Jeffrey Hanke	Signed
105	2020-03-27 12:15	Anonymous (not verified)	174.219.134.4	Elijah Willier	Proprietorship	805 SE 15th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-27	Elijah Willier	e.willier42798@gmail.com	Grimes	Polk	IA	Isaac Willier	Isaiah Willier	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah Willier	e.willier42798@gmail.com	Self/ sole proprietor	Grimes	Polk	IA	Isaac Willier	Isaiah Willier	Signed
1647	2023-05-15 14:11	Anonymous (not verified)	94.188.207.227	Innovators construction llc	Limited Liability Company	3234 180th St. Homestead, IA 52236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-15	Guadalupe Ramirez	info@jmdrywallonline.com	Homestead	Iowa	Iowa	Itali Ramírez	Manuela Muñoz	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan M Ramírez	info@jmdrywallonline.com	Owner/spouse	Homestead	Iowa	Iowa	Itali Ramírez	Manuela Muñoz	Signed
1739	2023-07-11 12:18	Anonymous (not verified)	94.188.205.169	Innovators Construction LLC	Limited Liability Company	3230 180th St. Homestead, IA 52236.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Juan Ramírez	info@jmdrywallonline.com	Homestead	Iowa	Iowa	Itali Ramírez	Guadalupe Ramirez	Signed	(1) The employer does not elect the employers’ liability coverage.	Guadalupe Ramirez	info@jmdrywallonline.com	Business partner	Homestead	Iowa	Iowa	Itali Ramírez	Juan M Ramírez	Signed
1740	2023-07-11 12:22	Anonymous (not verified)	94.188.205.168	Innovators Construction LLC	Limited Liability Company	3234 180th St., Homestead, IA 52236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Guadalupe Ramirez	imfo@jmdrywallonline.com	Homestead	Iowa	Iowa	Itali Ramírez	Juan m Ramírez	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan M Ramírez	info@jmdrywallonline.com	Business partner	Homestead	Iowa	Iowa	Itali Ramírez	Juan m Ramírez	Signed
2158	2024-04-17 11:47	Anonymous (not verified)	94.188.207.228	Mildred Lopez	Proprietorship	214 1st Ave SW Hampton, Iowa 50441	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Mildred Lopez Camacho	morrison.hpd@gmail.com	Hampton	Franklin	Iowa	Ixia Anduce	Mark Morrison	Signed	(1) The employer does not elect the employers’ liability coverage.	Mildred Lopez	morrison.hpd@gmail.com	Self	Hampton	Franklin	IOwa	Ixia Anduce	Mark Morrison	Signed
2159	2024-04-17 12:28	Anonymous (not verified)	94.188.207.229	Mildred Lopez Camacho	Proprietorship	214 1st Ave SW Hampton, Iowa 50441	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Mildred Lopez Camacho	morrison.hpd@gmail.com	Hampton	Franklin	Iowa	Ixia Anduce	Jonathan Morales	Signed	(1) The employer does not elect the employers’ liability coverage.	Mildred Lopez Camacho	morrison.hpd@gmail.com	Self	Hampton	Franklin	IOwa	Ixia Anduce	Jonathan Morales	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
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
1652	2023-05-17 20:44	Anonymous (not verified)	94.188.205.167	Fox Trucking	Proprietorship	2774 March Ave Greene Ia. 50636	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-17	Chet D. Fox	cjakfox@yahoo.com	Greene	Floyd	Iowa	Jack Dwyer	Chad Olson	Signed	(1) The employer does not elect the employers’ liability coverage.	Chet Fox	cjakfox@yahoo.com	myself	Greene	Floyd	Iowa	Jack Dwyer	Chad Olson	Signed
231	2020-08-13 18:22	Anonymous (not verified)	173.27.28.18	Kelley Contracting	Proprietorship	115 Pinecrest Circle Elk Run Heights, Ia 50707	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-13	Chad Kelley	chadkelley22@gmail.com	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kelley Contracting	chadkelley22@gmail.com	Self	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed
1474	2023-02-20 19:48	Anonymous (not verified)	94.188.207.230	Individual entity	Proprietorship	801 CELTIC DR, Waukee IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Gerardo Castro	jackiecastro18@gmail.com	Waukee	IA	United States	Jackelin Castro	Esmeralda Castro	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerardo Castro	jackiecastro18@gmail.com	self	Waukee	Dallas	Iowa	Jackelin Castro	Esmeralda Castro	Signed
1788	2023-08-07 18:32	Anonymous (not verified)	94.188.205.168	Johnson Custom Paint & Design LLC	Limited Liability Company	1414 N 9TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-07	Josh Johnson	johnsoncustompaint@hotmail.com	Fort Dodge	Iowa	United States	JACKLYN JOHNSON	Roger Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Johnson	johnsoncustompaint@hotmail.com	owner	Fort Dodge	IA	United States	JACKLYN JOHNSON	Roger Johnson	Signed
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
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
1525	2023-03-20 15:28	Anonymous (not verified)	94.188.205.174	Valentin Saucedo	Proprietorship	1811 W 5th St, Sioux City, IA 51103	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-20	Valentin Saucedo	sauceds20@gmail.com	Sioux City	Woodbury	IA	Jacob Goodin	Kevin Small	Signed	(1) The employer does not elect the employers’ liability coverage.	Valentin Saucedo	sauceds20@gmail.com	Sole Prop	Sioux City	Woodbury	IA	Jacob Goodin	Kevin Small	Signed
572	2021-07-13 09:59	Anonymous (not verified)	173.27.17.202	David Lochner	Proprietorship	866 40th ave Bettendorf Iowa 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-13	David Lochner	jnagel@leafhome.com	Dubuque	Dubuque	Iowa	Jacob Nagel	Shawn Cowell	Signed	(1) The employer does not elect the employers’ liability coverage.	David Lochner	jnagel@leafhome.com	Self	Dubuque	Dubuque	Iowa	Jacob Nagel	Shawn Cowell	Signed
574	2021-07-14 10:43	Anonymous (not verified)	173.27.17.202	Maxwell Taylor	Proprietorship	618 east Colorado St. Davenport Iowa 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-14	Maxwell Taylor	maxwelltaylor33@icloud.com	Davenport	Scott	Iowa	Jacob Nagel	Ty Reindl	Signed	(1) The employer does not elect the employers’ liability coverage.	Maxwell Taylor	maxwelltaylor33@icloud.com	Self	Davenport	Scott	Iowa	Jacob Nagel	Ty Reindl	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
582	2021-07-22 15:14	Anonymous (not verified)	173.24.111.218	Joseph Davis	Proprietorship	7257 Valley Dr, 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.	2021-07-22	Joseph Davis	jtigerd@live.com	Bettendorf	Scott	IA	Jacob nagel	Nick brewer	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph Davis	jtigerd@live.com	Agent	Bettendorf	IA	IA	Jacob nagel	Nick brewer	Signed
1795	2023-08-11 08:02	Anonymous (not verified)	94.188.205.176	Overall Cleaning	Proprietorship	507 Enterprise Ct #6 Independence IA 50644	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-11	Michelle L. Vonsprecken	michelle.vonsprecken@gmail.com	Independence	Buchanan	Iowa	Jacob Von Sprecken	Cody Caraway	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin C Hayes	overallcleaning21@gmail.com	Business Partner	Marion	Linn	IA	Cody Caraway	Jacob Von Sprecken	Signed
1019	2022-03-29 16:42	Anonymous (not verified)	104.201.100.158	Nayeri Group LLC	Limited Liability Company	412 SE 17th Court, 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.	2022-03-29	Sima Dehghan Nayeri	nayeri.sima@gmail.com	Grimes	Polk	Iowa	Jacob Willis	Lucas Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Sima Nayeri	nayeri.sima@gmail.com	Self	Grimes	Polk	Iowa	Jacob Willis	Lucas Peterson	Signed
837	2022-01-13 08:38	Anonymous (not verified)	169.197.65.8	Reyes Concrete Services llc	Limited Liability Company	101 Perry St South Jesup, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-13	Ronald Reyes	ronlreyes1975@gmail.com	Jesup	Buchanan	Iowa	Jacolin Reyes	Ronald Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald Reyes	ronlreyes1975@gmail.com	Same	Jesup	Buchanan	Iowa	Jacolin Reyes	Ronald Reyes	Signed
815	2021-12-28 12:29	Anonymous (not verified)	173.29.239.122	Comtek, Inc.	Proprietorship	3702 NW 13th St. Ankeny, Iowa 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-28	Micheal D. Qualley	mqcomtek@gmail.com	ANKENY	IA	United States	Jacque Blackman	Jeffery Keipper	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacque Blackman	jblackman@grimesfinancialgroup.com	client	Grimes	Polk	Iowa	Jacque Blackman	Jeffery Keipper	Signed
1079	2022-04-28 16:18	Anonymous (not verified)	3.217.29.203	John Paul Pokorny	Proprietorship	500 W Adams St., Creston, 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.	2022-02-04	John Paul Pokorny	tylerins@tyleriowa.com	Creston	Union	Iowa	Jacquie Merritt	Wendi Eslinger	Signed	(1) The employer does not elect the employers’ liability coverage.	John Paul Pokorny	tylerins@tyleriowa.com	Owner	Creston	Union	Iowa	Jacquie Merritt	Wendi Eslinger	Signed
1509	2023-03-09 10:39	Anonymous (not verified)	94.188.207.227	Andres Barboza	Limited Liability Company	329 West 31 St South Sioux city ne 68776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Andres Barboza	barboza79@yahoo.com	South Sioux City	Nebraska	United States	Jaime Gutierrez	Gerardo ibarra	Signed	(1) The employer does not elect the employers’ liability coverage.	Andres Barboza	barboza79@yahoo.com	Owner	South Sioux City	Nebraska	United States	Jaime Gutierrez	Gerardo ibarra	Signed
1775	2023-08-03 09:37	Anonymous (not verified)	94.188.207.227	J j builder llc	Limited Liability Company	2307 richland dr des moines ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-28	José Cruz Jasso balleza	jassoprimo03@icloud.com	Des moines	Polk	Iowa	Jaime Rodrigues	Mario ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Irving	iibarra@centroinsurance.com	Agent	Des moines	Polk	Iowa	Irving Ibarra	Jaime Rodrigues	Signed
536	2021-06-07 11:01	Anonymous (not verified)	205.221.255.62	Mark Lile	Limited Liability Partnership	PO Box 36411	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-07	Martin Luverne Humphrey Jr	martinhumphreu@gmail.com	Des Moines	Polk	Iowa	Jaimi Humphrey	George Porter	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Lile	Mark@ultimateautowash.com	Employer	Des Moines	Polk	Iowa	Jaimi Humphrey	George Porter	Signed
573	2021-07-14 09:12	Anonymous (not verified)	166.181.83.201	Dustin Demoss	Proprietorship	407 mechanic st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-13	Dustin Michael DeMoss	dustindemoss14@gmail.com	Monmouth	Iowa	United States	Jake	Jake	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Michael DeMoss	dustindemoss14@gmail.com	Idk	Monmouth	Iowa	United States	Jake	Jake	Signed
1267	2022-08-17 14:11	Anonymous (not verified)	174.192.75.162	Elijah wyant	Proprietorship	708 1/2 w 3rd st davenport ia 52802	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-17	Elijah wyant	Aidenwyant@gmail.com	Davenport	Scott	Iowa	Jake laxton	Courtney sanders	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah wyant	Aidenwyant@gmail.com	Self	Davenport	Scott	Iowa	Jake laxton	Courtney sanders	Signed
594	2021-08-03 13:12	Anonymous (not verified)	166.181.80.73	Leaffilter	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.	2021-08-03	Gerald Landstrum	Teamtony710@gmail.com	103 e Grinnell street Gibson Iowa	Keokuk	Iowa	Jake Nagel	Ty Reindl	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter Gutter Protection	jnagel@leafhome.com	assembler	Bettendorf	Scott	Iowa	Jake nagel	Ty reindl	Signed
2071	2024-03-01 11:08	Anonymous (not verified)	94.188.207.229	Level92 Screen Printing LLC	Limited Liability Company	2500 W 2nd Ave Ste 10, Indianola, IA 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-01	Alison Vice	orders@level92.com	Indianola	Warren	IA	Jake Vice	Grant Darrah	Signed	(1) The employer does not elect the employers’ liability coverage.	Alison Vice	orders@level92.com	Partner	Indianola	Warren	IA	Jake Vice	Grant Darrah	Signed
2094	2024-03-14 10:16	Anonymous (not verified)	94.188.207.225	Timothy Deutmeyer	Proprietorship	4014 iowa rd Center Point IA 52213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-14	Timothy Francis Deutmeyer	timothydeutmeyer65@gmail.com	Center Point	Linn	Iowa	JAKE. Mcnurlaen	Kevin Kinzebach	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Francis Deutmeyer	timothydeutmeyer65@gmail.com	Owner	CENTER POINT	Linn	Iowa	Jake Mcnurlaen	Kevin Kinzebach	Signed
959	2022-03-09 10:30	Anonymous (not verified)	207.199.231.172	Steve Shepherd	Proprietorship	332 N Walnut St Fremont, IA 52561	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-09	Steve Shepherd	sheps2s69@gmail.com	Fremont	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Shepherd	sheps2s69@gmail.com	Self	Fremont	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed
961	2022-03-09 15:06	Anonymous (not verified)	207.199.231.172	Scott Ullrick	Proprietorship	601 Grant St Beacon, IA 52534	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-09	Scott Ullrick	scottullrick@msn.com	Beacon	Mahaska	IA	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Ullrick	scottullrick@msn.com	Self	Beacon	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed
962	2022-03-09 16:45	Anonymous (not verified)	207.199.231.172	Thomas Whitehead	Proprietorship	1602 Green St Oskaloosa, IA 52577	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-09	Thomas Whitehead	roctomjj@mahaska.org	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Whitehead	roctomjj@mahaska.org	Self	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed
980	2022-03-16 09:38	Anonymous (not verified)	207.199.231.172	Sean Wursta	Proprietorship	401 Strawberry St Eddyville, IA 52553	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-16	Sean Wurstra	5wurstas@gmail.com	Eddyville	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Self	5wurstas@gmail.com	self	Mahaska	Eddyville	Iowa	James Anderson	Ashley Bryan	Signed
1011	2022-03-28 10:25	Anonymous (not verified)	207.199.231.172	Brian Carmer	Proprietorship	133 S Iowa Ave, Ottumwa, IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	Brian Carmer	b_carmer@yahoo.com	Ottumwa	Wapello	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Carmer	B_Carmer@yahoo.com	Self	Ottumwa	Wapello	Iowa	James Anderson	Ashley Bryan	Signed
826	2022-01-10 12:26	Anonymous (not verified)	104.128.43.204	Wolfman Trucking, LLC	Limited Liability Company	406 S Lawrence St, Bazine, KS 67516	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-10	JR Steckline	wolfmantrucking317@gmail.com	Bazine	Ness	Kansas	James Babcock	Darin Wittman	Signed	(1) The employer does not elect the employers’ liability coverage.	JR Steckline	wolfmantrucking317@gmail.com	Owner	Bazine	Ness	Kansas	James Babcock	Darin Wittman	Signed
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
845	2022-01-20 09:06	Anonymous (not verified)	208.126.69.10	KenX Pest Control	Limited Liability Company	350 2nd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-20	Ken YARRINGTON	kenxpestcontrol@hotmail.com	Truro	IA	IA	James Gage	Kent Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Kenneth Charles Yarrington	kenxpestcontrol@hotmal.com	Myself	Truro	IA	IA	James Gage	Kent Smith	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
1789	2023-08-08 13:18	Anonymous (not verified)	94.188.207.230	Corridor Construction Co., LLC	Limited Liability Company	P.O. Box 8540 Cedar Rapids, IA 52408	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-08	Steven H. Miller	jimfortmann60@gmail.com	Cedar Rapids	Linn	IA	James J. Fortmann	Ruth Ann Beers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven H. Miller	jimfortmann60@gmail.com	Member	Cedar Rapids	Linn	IA	James J. Fortmann	Ruth Ann Beers	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
605	2021-08-16 16:06	Anonymous (not verified)	67.55.155.46	COMPLETE CONSTRUCTION SERVICES LLC	Limited Liability Company	718 FOX RUN	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-16	DAVID BOWER	BOWERD@OSKYCSD.ORG	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed	(1) The employer does not elect the employers’ liability coverage.	DAVID BOWER	BOWERD@OSKYCSD.ORG	PRESIDENT	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed
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
996	2022-03-22 23:37	Anonymous (not verified)	173.27.235.109	patriot t services	Proprietorship	205 park st carlisle , ia 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-22	TRAVIS KEENEY	knytrav@aol.com	carlisle	warren	iowa	james Ren	Jesse Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Keeney	knytrav@aol.com	myself	carlisle	warren	iowa	james ren	jesse parker	Signed
1493	2023-03-05 22:42	Anonymous (not verified)	94.188.207.226	Wyckoff Heating and Cooling	Proprietorship	95 hwy 5 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.	2023-03-05	Travis Keeney	knytrav@aol.com	carlisle	warren	iowa	James Ren	Troy Keeney	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Keeney	knytrav@aol.com	Subcontractor	carlisle	warren	iowa	James Ren	Troy Keeney	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
2179	2024-04-25 10:58	Anonymous (not verified)	94.188.205.177	Loonpa Landscaping LLC	Limited Liability Partnership	5309 Red Oak Ln Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-25	Brent Barloon	Brent@barerootslawn.care	WAterloo	Black Hawk	Iowa	James White	Kari White	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Daniel White	danny@barerootslawn.care	Owner	Cedar Falls	Black Hawk	Iowa	James White	Kari White	Signed
2166	2024-04-20 13:38	Anonymous (not verified)	94.188.205.175	Cedar Valley Seamless, LLC	Limited Liability Company	1184 215th St, Jesup, IA 50648	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-20	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Owner/Operator	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed
1667	2023-05-29 22:31	Anonymous (not verified)	94.188.207.226	All J Acres	Limited Liability Company	13522 120th Ave, Ottumwa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-26	Jonathan Bunt	jonbunt@gmail.com	Ottumwa	Wapello	IA	James Williamson	James Ash	Signed	(1) The employer does not elect the employers’ liability coverage.	Jonathan Bunt	jonbunt@gmail.com	Self	Ottumwa	Wapello	IA	James Williamson	James Ash	Signed
1055	2022-04-15 20:06	Anonymous (not verified)	166.181.87.86	Steve MORRISON Trucking	Proprietorship	P.O. Box 66 105 N Elm Danville, IA 52623	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Stephen Dwight Morrison	sdmt13@gmail.com	Danville	Des Mounes	IA	Jamie Brown	William Samples	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Dwight Morrison	sdmt13@gmail.com	Owner	Danville	Des Moines	IA	Jamie Brown	William Samples	Signed
1650	2023-05-16 12:06	Anonymous (not verified)	94.188.207.225	R & J Transport	Proprietorship	85152 US HWY 81 PIERCE NE 68767	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-16	Ray Tom Clausen III	jamieleabeutler2013@gmail.com	Pierce	NE	United States	Jamie Clausen	Ann Siebrandt	Signed	(1) The employer does not elect the employers’ liability coverage.	Ray T Clausen III	jamieleabeutler2013@gmail.com	Owner	Pierce	Pierce	Ne	Jamie Clausen	Ann Siebrandt	Signed
1277	2022-08-22 08:57	Anonymous (not verified)	68.169.247.177	Andrew Betts	Proprietorship	305 3rd ave sw cascade ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Andrew Betts	dbidrywallco@gmail.com	Cascade	Dubuque	Iowa	Jamie manternach	Andy hall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Betts	dbidrywallco@gmail.com	Owner	Cascade	Iowa	United States	Jamie manternach	Andy hall	Signed
751	2021-11-16 15:51	Anonymous (not verified)	166.181.83.87	Dylan Wilson SMS & More	Proprietorship	7500 25th Milan IL 61264	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-16	Dylan Wilson	doe33843@gmail.com	Milan	Rock Island	IL	Jamie Short	Brett Dawson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Groech	wilsoncrazy@gmail.com	Grandmother	Moline	Rock Island	IL	Jamie Short	Brett Dawson	Signed
480	2021-04-14 15:58	Anonymous (not verified)	65.103.82.36	Home Cleaning Services	Proprietorship	1448 w 13th St Davenport IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Jolene Lyn Brown	j@gmail.com	davenport	scott	IA	Jamie Swanson	Andrew Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jolene Brown	j@gmail.com	owner	davenport	Scott	IA	Jamie Swanson	andrew Swanson	Signed
1256	2022-08-15 13:22	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.	2022-08-08	Richard Miller	rmiller0574@gmail.com	Davenport	Iowa	United States	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
1257	2022-08-15 13:27	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.	2022-08-15	Amanda Carol Loeffelholz	evansamanda300@yahoo.com	Davenport	Iowa	United States	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
1258	2022-08-15 13:30	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.	2022-08-15	George Anthony Loeffelholz	tobby.loeffelholz@gmail.com	Davenport	Iowa	United States	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
1259	2022-08-15 13:47	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.	2022-08-15	Johnathan Scott	karma27895@gmail.com	East Moline	Rock Island	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
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
1274	2022-08-19 13:34	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.	2022-08-19	Phillip Hoxsey	phillhoxey81@gmail.com	Davenport	Scott	Iowa	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	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
1275	2022-08-19 13:40	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.	2022-08-19	Jonas Martinez	jonasmartinez0202@icloud.com	Iowa City	Johnson	Iowa	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	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
1276	2022-08-19 13:43	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.	2022-08-19	Allen Aldridge	allenaldridge73@yahoo.com	Davenport	Scott	Iowa	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	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
1283	2022-08-25 10:23	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.	2022-08-25	Christopher Payne	service@paynedrywall.com	Davenport	Scott	Iowa	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	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
1297	2022-09-07 09:36	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.	2022-09-07	Dagoberto Nunez	nunezdogoberto730@gmail.com	Iowa City	Johnson	Iowa	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	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
1298	2022-09-07 09:58	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.	2022-09-07	Derek Sherwodd	sherwoodpainting@hotmail.com	Davenport	Scott	Iowa	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	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
1313	2022-09-19 11:03	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.	2022-09-19	Merle Broihier	premiere_pd_llc@yahoo.com	Bettendorf	Scott	Iowa	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	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
158	2020-05-18 13:58	Anonymous (not verified)	108.59.100.21	LNM Truck & Trailer Repair LLC	Limited Liability Company	902 Rossville Rd, Waukon, IA 52172	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-05-18	Matthew Hawkins	lnmtruckandtrailerrepair@gmail.com	Waterville	Allamakee	IA	Jane M Regan	Chelsea Whalen	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Matthew Hawkins	lnmtruckandtrailerrepair@gmail.com	Owner	Waterville	Allamakee	IA	Jane M Regan	Chelsea Whalen	Signed
1201	2022-07-11 20:19	Anonymous (not verified)	108.59.100.21	Craig A Selberg dba Selberg Construction	Proprietorship	853 North Fork Hollow Rd, Waukon IA 52172	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-11	Craig A Selberg	selberg.construction65@gmail.com	Waukon	Allamakee	Iowa	Jane M Regan	Nancy K Bechtel	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig A Selberg	selberg.construction65@gmail.com	Employer/Owner	Waukon	Allamakee	Iowa	Jane M Regan	Nancy K Bechtel	Signed
2144	2024-04-10 14:23	Anonymous (not verified)	94.188.205.176	Heaven Sent PC LLC	Limited Liability Company	604 Allamakee St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-10	Justin PIggott	heavensentpetcremation@gmail.com	Waukon	Allamakaee	IA	Jane M Regan	Nancy Bechtel	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Piggott	heavensentpetcremation@gmail.com	LLC Member	Waukon	Allamakee	IA	Jane M Regan	Nancy Bechtel	Signed
1178	2022-07-05 12:02	Anonymous (not verified)	172.58.122.51	Wright home restoration	Limited Liability Company	2914 South Union 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.	2022-07-05	Matthew Wright	wright.home.restoration@gmail.com	Des Moines	IA	United States	Jane wright	Robert wright	Signed	(1) The employer does not elect the employers’ liability coverage.	Wright home restoration	wright.home.restoration@gmail.com	Myself	Des Moines	IA	United States	Jane wright	Robert Wright	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
1507	2023-03-09 08:16	Anonymous (not verified)	94.188.207.230	Greufe Construction	Proprietorship	2820 230th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Wayne Greufe	wgreufe@wmtel.net	Blairsburg	US	United States	Janet Greufe	Janet Greufe	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Greufe	wgreufe@wmtel.net	Friend	Blairsburg	US	United States	Janet Greufe	Janet Greufe	Signed
30	2020-01-07 08:34	Anonymous (not verified)	199.10.5.7	Data Information Management LLC	Limited Liability Company	703 Bluff St Dubuque IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-07	Stephen M Schauff	steve@caricomm.com	Dubuque	Iowa	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher R Broessel	chris@caricomm.com	Partner	Dubuque	Iowa	IA	Janet L Schauff	Morris P schauff	Signed
31	2020-01-07 08:37	Anonymous (not verified)	199.10.5.7	Data Information Management LLC	Limited Liability Company	703 Bluff St Dubuque IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-07	Christopher R Broessel	chris@caricomm.com	Dubuque	Dubuque	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen M schauff	steve@caricomm.com	Partner	Dubuque IA	Dubuque	Iowa	Janet L schauff	Morris P Schauff	Signed
106	2020-03-31 10:42	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	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	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
362	2021-01-14 12:15	Anonymous (not verified)	173.26.157.255	Shear Bliss Pet Salon	Limited Liability Company	824 Ansborough Ave. Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-14	Sarah K Bebee	shearblisspet@aol.com	Hudson	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Bebee	shearblisspet@aol.com	self	Hudson	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed
363	2021-01-14 12:17	Anonymous (not verified)	173.26.157.255	Shear Bliss Pet Salon	Limited Liability Company	824 Ansborough Ave. Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-14	Melissa Kay Herold	shearblisspet@aol.com	Cedar Falls	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed	(1) The employer does not elect the employers’ liability coverage.	Meliss Kay Herold	shearblisspet@aol.com	self	Cedar Falls	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed
1555	2023-04-05 08:03	Anonymous (not verified)	94.188.207.227	DK Motor Freight	Proprietorship	3621 Tyler Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-05	David Kirchner	dkirchner89@gmail.com	Hartley	Obrien	Iowa	Janna VanDonge	Chad Driesen	Signed	(1) The employer does not elect the employers’ liability coverage.	David Kirchner	dkirchner89@gmail.com	Self	Hartley	Iowa	United States	Janna VanDonge	Chad Driesen	Signed
2201	2024-05-06 10:42	Anonymous (not verified)	94.188.207.226	Trent Hatlen	Proprietorship	1042 490th Street, Rembrandt, IA 50576	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-06	Trent Hatlen	trentgotti@yahoo.com	Rembrandt	Buena Vista	Iowa	Jared Brashears	Katie Gunkelman	Signed	(1) The employer does not elect the employers’ liability coverage.	Trent Hatlen	trentgotti@yahoo.com	Owner	Rembrandt	Buena Vista	Iowa	Jared Brashears	Katie Gunkelman	Signed
1312	2022-09-17 15:29	Anonymous (not verified)	97.125.242.121	Heartland Blinds	Limited Liability Company	1255 Emmons St, Hiawatha, IA 52233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-17	Phil Murray	proinstallia@yahoo.com	Hiawatha	Linn	IA	Jared Metcalf-Murray	Jeremy Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Christene Murray	chrissymurray57@yahoo.com	Self	Hiawatha	Linn	IA	Jared Metcalf-Murray	Jeremy Murray	Signed
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
7	2019-11-15 12:26	Anonymous (not verified)	173.17.129.166	Thomas C. Davis	Proprietorship	3509 Franklin 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.	2019-11-15	Thomas C. Davis III	thomas.davis.iii@gmail.com	Des Moines	Polk	Iowa	Jared Vincent	Kevin Corn	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas C. Davis III	thomas.davis.iii@gmail.com	Employer	Des Moines	Polk	Iowa	Jared Vincent	Kevin Corn	Signed
2084	2024-03-08 15:18	Anonymous (not verified)	94.188.207.230	Heidi Vincent	Proprietorship	2213 SW White Birch Dr, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	Heidi Vincent	jared.vincent@insurancestationinc.com	Ankeny	Polk	Iowa	Jared Vincent	Colton Horak	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Jared Vincent	Colton Horack	Signed
2085	2024-03-08 15:22	Anonymous (not verified)	94.188.207.227	Laura Cook	Proprietorship	2213 SW White Birch Dr, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	Laura Cook	jared.vincent@insurancestationinc.com	Ankeny	Polk	Iowa	Jared Vincent	Colton Horak	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Jared Vincent	Colton Horack	Signed
548	2021-06-24 22:08	Anonymous (not verified)	173.31.28.69	Brown's Window Cleaning +PLUS	Proprietorship	700 11th Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-24	Lawrence Brown	brownswindowcleaningplus@gmail.com	Altoona	Iowa	United States	Jason Alderman	Colette Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Lawrence Brown	brownswindowcleaningplus@gmail.com	Self	Altoona	Iowa	United States	Jason Alderman	Colette Evans	Signed
968	2022-03-11 15:39	Anonymous (not verified)	64.191.6.226	Wedeking Custom Comfort LLC	Limited Liability Company	17541 Ridge Ave Clarksville, IA 50619	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Justin Wedeking	wedeking42@gmail.com	Clarksville	Butler	Iowa	Jason Grant	Richard Grant	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Wedeking	wedeking42@gmail.com	Self	Clarksville	butler	Iowa	Jason Grant	Richard Grant	Signed
991	2022-03-21 15:25	Anonymous (not verified)	64.191.6.226	Wheeler Painting	Proprietorship	102 Maple Circle Waverly Iowa 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.	2022-03-21	Jon Wheeler	jon.wheeler67@gmail.com	Waverly	Bremer	Iowa	Jason Grant	Richard Grant	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon Wheeler	jon.wheeler67@gmail.com	Owner	Waverly	Bremer	Iowa	Jason Grant	Richard Grant	Signed
1567	2023-04-12 10:01	Anonymous (not verified)	94.188.205.177	Hearts on fire llc	Limited Liability Partnership	931 14th Ave Se Altoona Iowa 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-12	Matt Moffet	dsm@fibrenew.com	Altoona	Polk	Iowa	Jason McDowell	Mike Wennekamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Moffet	dam@fibrenew.com	Owner	Altoona	Polk	Iowa	Jason McDowell	Mike Wennekamp	Signed
1973	2024-01-02 17:05	Anonymous (not verified)	94.188.207.227	Diego Puente	Proprietorship	1420 north st, apt#3 Perry Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Diego Puente Martinez	diegopuente0655@gmail.com	Perry	Dallas	Iowa	Jason Van Dyke	Ashley Heffernen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Van Dyke	jvandyke@thermalshop.com	worker	Cedar Rapids	Iowa	United States	Jason Van Dyke	Ashley Heffernen	Signed
2045	2024-02-15 10:26	Anonymous (not verified)	94.188.207.227	Francesco Martinez	Proprietorship	403th 7th Ave NW Clarion IA 50525	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-15	Francesco Martinez	Martinexfrancesco99@gmail.com	Clarion	Wright	Iowa	Jason W Helmers	Josh W Helmers	Signed	(1) The employer does not elect the employers’ liability coverage.	Francesco Martinez	martinezfrancesco99@gmail.com	Employer	Clarion	Wright	Iowa	Jason W Helmers	Josh W Helmers	Signed
1428	2023-01-23 19:31	Anonymous (not verified)	206.72.6.241	Brian Grote	Limited Liability Company	919 Highway 37	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-23	Brian Grote	grote919@gmail.com	Earling	Iowa	United States	Jaurel Grote	Dan Grote	Signed	(1) The employer does not elect the employers’ liability coverage.	Leinen Construction	grote919@gmail.com	sub	Harlan Iowa	Iowa	United States	Jaurel Grote	Dan Grote	Signed
687	2021-10-22 11:07	Anonymous (not verified)	65.144.174.26	Fernando Garcia	Proprietorship	8952 Long Meadow Dr Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Fernando Garcia	gfernando5030@gmail.com	johnston	polk	Iowa	Javier Manriquez	Josefina Chavez	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Garcia	gfernando5030@gmail.com	Owner	Johnston	Polk	Iowa	Javier Manriquez	Josefina Chavez	Signed
1849	2023-09-19 14:57	Anonymous (not verified)	94.188.207.228	Iowa painting solutions llc	Limited Liability Company	2500 pleasant st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-19	Patricia Davalos	iowapaintingsolutionsllc@gmail.com	Des Moines	Polk	Iowa	Javier Rascon	Angel Perez	Signed	(1) The employer does not elect the employers’ liability coverage.	Iowa painting solutions llc	iowapaintingsolutionsllc@gmail.com	Owner	Des Moines	Polk	Iowa	Javier Rascon	Angel Perez	Signed
1075	2022-04-28 07:53	Anonymous (not verified)	172.58.160.241	E & J Roofing LLC	Limited Liability Company	5008 SE 5th Street Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-28	E & J Roofing LLC	janeylli2006@hotmail.com	Des Moines	United States	Iowa	Javier Solís Saldaña	Arhely S. Saldaña	Signed	(1) The employer does not elect the employers’ liability coverage.	E & J Roofing LLC	janeylli2006@hotmail.com	Owner	Des Moines	Polk	Iowa	Javier Solís Saldaña	Arhely S. Saldaña	Signed
1452	2023-02-13 16:49	Anonymous (not verified)	94.188.207.228	The Wine Shop, LLC	Limited Liability Company	305 Main St, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-02-13	Dana Swasand	danaswasand@rocketmail.com	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Dana Swasand	danaswasand@rocketmail.com	Owner/Member	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed
1720	2023-07-05 07:19	Anonymous (not verified)	94.188.207.224	Doug FGerneding	Proprietorship	21618 270th St Carroll IA 51401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-05	Doug Ferneding	dougferneding@gmail.com	Carroll	Iowa	Iowa	Jaynie Ferneding	Brenda Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Ferneding	dougferneding@gmail.com	same	Carroll	Iowa	Iowa	Jaynie Ferneding	Brenda Klein	Signed
1948	2023-12-11 10:36	Anonymous (not verified)	94.188.207.224	Just Like New Details LLC	Limited Liability Company	4665 NE 7th 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.	2023-12-11	Trinity Schroeder	trinity@justlikenewdetails.com	Des Moines	Polk	Iowa	Jayson Jones	Nikki Wilks	Signed	(1) The employer does not elect the employers’ liability coverage.	Trinity Schroeder	trinity@justlikenewdetails.com	Member	Des Moines	Polk	Iowa	Jayson Jones	Nikki Wilks	Signed
2008	2024-01-29 14:45	Anonymous (not verified)	94.188.207.230	DB2P	Limited Liability Company	5904 Ashworth Road	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Arjun Dahal	allcoolliquors@gmail.com	West Des Moines	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed	(1) The employer does not elect the employers’ liability coverage.	Jayson Jones	jayson@jonesinsured.com	Insurance Agent	Urbandale	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed
2114	2024-03-25 18:18	Anonymous (not verified)	94.188.207.227	Lisa V Blessington	Proprietorship	411 S 10th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-25	Lisa Varie Blessington	lblessington@yahoo.com	Sac City	Sac	IA	Jean Rexroat	Jennifer Tovar	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Varie Blessington	lblessington@yahoo.com	Same	Sac City	Sac	IA	Jean Rexroat	Jennifer Tovar	Signed
1177	2022-07-05 10:01	Anonymous (not verified)	172.58.85.103	Leaf Guard	Limited Liability Partnership	3060 SE Grimes Blvd, suite 100	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-04	Sean Gray	Totaldemo94@gmail.com	Des Moines	Polk county	Iowa	Jeanie Lu	Terra McAllister	Signed	(1) The employer does not elect the employers’ liability coverage.	Leaffilter North LLC	leaffilter@leafhome.com	Worker	Des moines	Polk county	IA	Jeanie Lu	Terra McAllister	Signed
598	2021-08-06 19:04	Anonymous (not verified)	107.77.208.84	Paul Adams	Proprietorship	914 Bayfield drive Denton TX 76209	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-06	Paul T Adams	ptadams61@yahoo.com	Denton	Denton	Tx	Jeanie Moses	Richard Moses	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul T Adams	ptadams61@yahoo.com	Friends	Milan	Rock Island	Illinois	Jeanie Moses	Richard Moses	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
614	2021-08-20 12:20	Anonymous (not verified)	172.58.235.242	Darren Qualls	Proprietorship	1515 Dewitt St. Ellsworth. IA 50075	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Darren Wade Qualls	d.qualls@outlook.com	Ellsworth	Hamilton	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed	(1) The employer does not elect the employers’ liability coverage.	Darren Wade Qualls	d.qualls@outlook.com	Self/Proprietor	Ellsworth	IA	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed
1761	2023-07-26 08:40	Anonymous (not verified)	94.188.207.224	Gerk Trucking	Proprietorship	401 W college, Stacyville, IA 50476	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Charles W. Gerk	cwgerk@gmail.com	Stacyville	Mitchell	iowa	Jeannie Lemke	Robin Tabbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles W. Gerk	cwgerk@gmail.com	Same	Stacyville	Mitchell	Iowa	Jeannie Lemke	Robin Tabbert	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
1365	2022-11-09 15:42	Anonymous (not verified)	173.189.165.11	Todd Nelson DBA: TSTR Custom Woodworking	Proprietorship	625 West Sovers St, Solon, IA 52333	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-09	Todd Nelson	tstr4040@gmail.com	Solon	Johnson	Iowa	Jeff Bair-Agent	Ryan Hajek	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd Nelson	tstr4040@gmail.com	Owner/Manager	Solon	Johnson	IA	Jeff Bair	Ryan Hajek	Signed
626	2021-08-31 11:39	Anonymous (not verified)	166.181.81.253	Birds landscape maintenance LLC	Limited Liability Company	1307 w 4th st south	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-31	Michael Alan bird	birdslawn@hotmail.com	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Alan bird	birdslawn@hotmail.com	Same - owner	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed
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
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
806	2021-12-20 08:56	Anonymous (not verified)	50.124.217.66	Lyndon L Giese dba G&G Farms Trucking	Proprietorship	402 St Olaf Ave S Canby, MN 56220	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-20	Lyndon L Giese	ldgiese@frontiernet.net	Canby	Yellow Medicine	Minnesota	Jeff Sinn	Tiffany Gohr	Signed	(1) The employer does not elect the employers’ liability coverage.	Lyndon L Giese	ldgiese@frontiernet.net	Owner	Canby	Yellow Medicine	Minnesota	Jeff Sinn	Tiffany Gohr	Signed
892	2022-02-03 15:52	Anonymous (not verified)	204.155.61.217	JD DRYWALL	Proprietorship	503 9th Street Kalona, Iowa 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-03	John Duwa	johnduwa@outlook.com	Kalona	Washington	Iowa	Jeff Spenner	Angela Stutzman	Signed	(1) The employer does not elect the employers’ liability coverage.	JD Drywall - John Duwa	johnduwa@outlook.com	owner	Kalona	Washington	Iowa	Jeff Spenner	Angela Stutzman	Signed
319	2020-11-16 19:24	Anonymous (not verified)	173.30.37.132	Nathan Wright	Proprietorship	500 2nd Avenue, Charles City, Iowa 50616	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-16	Nathan Robert Wright	nrwright85@yahoo.com	Charles City	Floyd	Iowa	Jeff Wright	Marsha Wright	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Robert Wright	nrwright85@yahoo.com	Self	Charles City	IA	IA	Jeff Wright	Marsha Wright	Signed
39	2020-01-19 11:00	Anonymous (not verified)	75.163.84.145	Allen L Bryen	Proprietorship	2609 Madison St Bellevue NE 68005	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-19	Allen Lee Bryen	Allen.Bryen@yahoo.com	Bellevue	Sarpy	Nebraska	Jeffrey Coats	Donald Coats	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen L Bryen	Allen.Bryen@yahoo.com	Self	Bellevue	Sarpy	Nebraska	jeffrey Coats	Donald Coats	Signed
73	2020-02-21 13:44	Anonymous (not verified)	192.30.185.233	Viejos Masnry construction LLC	Limited Liability Company	1708 Villa Ave. Sioux City IA 51103	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-13	Oscar Castro Ramirez	veijosconstruction@gmail.com	Sioux City	Woodbury	Iowa	JEFFREY H MCCLINTOCK	Nancy Fleming	Signed	(1) The employer does not elect the employers’ liability coverage.	Viejos Masonry Construction LLC	veijosconstruction@gmail.com	Owner/President	SIOUX CITY	Woodbury	Iowa	Nancy Fleming	Jeffrey Hugh McClintock	Signed
628	2021-09-01 09:39	Anonymous (not verified)	204.155.61.217	Utzinger Epoxy & Concrete, LLC	Limited Liability Company	1595 Highway 1 Washington, Iowa 52353	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Troy Utzinger	tbutzinger99@kctc.net	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Utzinger	tbutzinger99@kctc.net	owner	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
629	2021-09-01 09:44	Anonymous (not verified)	204.155.61.217	Thrapp Electric	Proprietorship	708 2nd Street Wellman, Iowa 52356	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Jay Thrapp	socketman5555@hotmail.com	Wellman	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Thrapp	socketman5555@hotmail.com	Owner	Wellman	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
637	2021-09-10 15:15	Anonymous (not verified)	204.155.61.217	Duwa Waterproofing LLC	Limited Liability Company	1548 150th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-10	Stacy Duwa	duwawaterproofing@gmail.com	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	owner	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed
1769	2023-07-31 11:23	Anonymous (not verified)	94.188.207.228	PSI LLC	Limited Liability Company	2765 N Center Point Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-31	Esteici Reyes	stacy0979@gmail.com	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	Signed	(1) The employer does not elect the employers’ liability coverage.	Esteici Reyes	stacy0979@gmail.com	Owner	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	Signed
1050	2022-04-14 14:55	Anonymous (not verified)	173.18.22.217	L & L Home Solutions	Limited Liability Company	3909 sw 14th st DSM 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.	2022-04-14	Abraham LaMark	landlhs@gmail.com	des moines	Polk	IA	Jen Lambert	william schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Abraham LaMark	landlhs@gmail.com	friend	des moines	polk	IA	Jen LAmbert	william schuldt	Signed
207	2020-07-16 13:05	Anonymous (not verified)	173.16.140.254	Steve Kennedy	Proprietorship	5108 SW 13th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-16	Steve Kennedy	stevekennedy@gmail.com	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Kennedy	stevekennedy007@gmail.com	Owner	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed
345	2020-12-29 09:20	Anonymous (not verified)	173.18.16.129	Eben-Ezer Concrete Services	Proprietorship	1283 dixon st. Des Moines IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-29	Saul Artero	Artro50313@yahoo.com	Des Moines	Polk	Iowa	Jen Lambert	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Saul Artero	Artro50313@yahoo.com	owner	des moines	Polk	Iowa	Jen Lambert	Lesa Reeves	Signed
355	2021-01-11 16:29	Anonymous (not verified)	173.18.16.129	Neil Bitting Construction	Proprietorship	2607 E 39th ct 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.	2021-01-11	Neil Bitting	bittingneil@live.com	des Moines	polk	Iowa	Jen Lambert	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Neil Bitting	bittingneil@live.com	owner	des moines	polk	Iowa	Jen Lambert	Lesa Reeves	Signed
415	2021-03-01 17:06	Anonymous (not verified)	208.126.61.78	Fryes Tree Service	Proprietorship	P.O. Box 244 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.	2021-03-01	Don Johnson	fts.don@gmail.com	Webster City	Hamilton	IA	Jenna Shaw	Tim Turner	Signed	(1) The employer does not elect the employers’ liability coverage.	Don Johnson	fts.don@gmail.com	Owner	Webster City	Hamilton	IA	Jenna shaw	Tim Turner	Signed
1932	2023-12-01 20:02	Anonymous (not verified)	94.188.205.168	Wasabi Johnston LLC	Limited Liability Company	2965 SE Timberline dr, Waukee, IA, 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Enjin zheng	jimmyzheng1573@gmail.com	Waukee	Dallas	Iowa	Jenna Yu	Wen Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Enjin zheng	jimmyzheng1573@gmail.com	Owner	Waukee	Dallas	Iowa	Jenna Yu	Wen Zheng	Signed
1255	2022-08-15 11:18	Anonymous (not verified)	173.215.77.92	Abby Snyder Design LLC	Limited Liability Company	1540 SE Greenbriar Circle, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-15	Abby Mae Snyder	abby.mae.snyder@gmail.com	Waukee	Dallas	Iowa	Jenni Wiig	Katy Hildman	Signed	(1) The employer does not elect the employers’ liability coverage.	Abby Mae Snyder	abby.mae.snyder@gmail.com	Self	Waukee	Dallas	Iowa	Jenni Wiig	Katy Hildman	Signed
127	2020-04-24 09:18	Anonymous (not verified)	63.152.82.5	TD Auto Services LLC	Limited Liability Company	451 W Parker St Waterloo IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-27	Dakoda Sellers	dakoda.d.sellers@gmail.com	Waverly	Bremer	IA	Jennie Roster	Dustin Roster	Signed	(1) The employer does not elect the employers’ liability coverage.	Dakoda D Sellers	dakoda.d.sellers@gmail.com	Owner	Waverly	Bremer	IA	Jennie Roster	Dustin Roster	Signed
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
2112	2024-03-22 08:22	Anonymous (not verified)	94.188.205.174	WR TREE SERVICES	Limited Liability Company	1176 highway 9 Lansing iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-22	Wesley Adam Remund	wesleyadamremund@gmail.com	Lansing	Allamakee	Iowa	JENNIFER K Harris	Stefan M Remund	Signed	(1) The employer does not elect the employers’ liability coverage.	Wesley Adam Remund	wesleyadamremund@gmail.com	OWNER	Lansing	Allamakee	Iowa	Jennifer K Harris	Stefan M Remund	Signed
1589	2023-04-20 12:57	Anonymous (not verified)	94.188.205.167	Grace Flooring	Proprietorship	2001 W 2nd Street perry, Iowa 50220	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-20	Ryan Michael Tool	GraceFlooring0@gmail.com	Perry	Dallas	IA	Jennifer Lynn Tool	Shane Workman	Signed	(1) The employer does not elect the employers’ liability coverage.	Grace Flooring	GraceFlooring0@gmail.com	Owner	Perry	Dallas	IA	Jennifer Tool	Shane workman	Signed
1389	2022-12-11 12:36	Anonymous (not verified)	24.149.1.5	Project Fix It LLC	Limited Liability Company	1303 Washington Street Cedar Falls Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-12	Adam L Reiter	adam.reiter@projectfixit.net	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Project Fix It	adam.reiter@projectfixit.net	Owner	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed
473	2021-04-13 11:26	Anonymous (not verified)	65.103.82.36	Quality Renovation	Proprietorship	1406 25th st Moline IL 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-06-21	Clarence Marvin Skipton	marvinthemartien77@gmail.com	Buffalo	Scott	IA	Jennifer Skipton	Rose mary Skipton	Signed	(1) The employer does not elect the employers’ liability coverage.	Clarence Marvin Skipton	marvinthemartien77@gmail.com	Owner	Moline	Rock Island	IL	Jennifer skipton	rose Skipton	Signed
2192	2024-04-29 13:15	Anonymous (not verified)	94.188.205.166	ElmStreet Apothecary	Limited Liability Company	320 W Kimberly Road #227	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Erica McGee	esalsbury07@gmail.com	Bettendorf	Scott	Ia	Jennifer West	Julie Francis	Signed	(1) The employer does not elect the employers’ liability coverage.	Erica McGee	esalsbury07@gmail.com	Self	Bettendorf	Scott	Ia	Jennifer West	Julie Francis	Signed
1836	2023-09-11 09:26	Anonymous (not verified)	94.188.205.174	Felisha Schmitz	Proprietorship	505 Q AVENUE MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-08	FELISHA SCHMITZ	PETERNFISH@GMAIL.COM	MILFORD	DICKINSON	IA	JENNIFER YOUNGWIRTH	TAMI KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	FELISHA SCMITZ	PETERNFISH@GMAIL.COM	SELF	MILFORD	DICKINSON	IA	JENNIFER YOUNGWIRTH	TAMI KLEIN	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
530	2021-05-25 08:30	Anonymous (not verified)	159.242.43.24	FoxTrot Foods, LLC	Limited Liability Company	13-15 S Federal Ave, Mason City IA 50401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-25	Melissa Fabian	melissafabian@yahoo.com	Mason City	Cerro Gordo	Iowa	Jenny McIntyre	Dan Wunschel	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Fabian	melissafabian@yahoo.com	Owner-Member	Mason City	Cerro Gordo	Iowa	Jenny McIntyre	Dan Wunschel	Signed
2146	2024-04-12 11:42	Anonymous (not verified)	94.188.207.226	Ken McGraw	Proprietorship	162 Green St Center Point IA 52213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-12	Ken Mcgraw	kenmcgraw1974@gmail.com	Center Point	Linn	Iowa	Jenny Vaske	Bob Nissen	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Cedar Rapids	Linn	Iowa	Bob Nissen	Jenny Vaske	Signed
1347	2022-10-26 14:42	Anonymous (not verified)	173.21.223.66	Mid American Roofing	Limited Liability Company	811 8th St Kalona IA 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-26	Josiah Hoyt	midamericanroofing@gmail.com	KALONA	IA	United States	Jensen Ropp	Randy Ropp	Signed	(1) The employer does not elect the employers’ liability coverage.	Josiah Hoyt	josiahhoyt@gmail.com	Owner	KALONA	IA	United States	Jensen Ropp	Randy Ropp	Signed
1550	2023-03-31 13:35	Anonymous (not verified)	94.188.205.177	Nadarevic Group LLC	Limited Liability Company	3633 NW 177th Ct, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-31	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Owner	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed
1551	2023-03-31 13:37	Anonymous (not verified)	94.188.205.176	Nadarevic Group LLC	Limited Liability Company	3633 NW 177th Ct, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-31	Nicole Nadarevic	niki@silverstonedevgroup.com	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Owner	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed
977	2022-03-15 12:04	Anonymous (not verified)	38.108.136.192	Gunner Fogle	Proprietorship	307 S. Franklin St. Corydon, IA 50060	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	Gunner Lee Fogle	gunnerfogle@hotmail.com	Corydon	Wayne	IA	Jeremy Fogle	Erika Fogle	Signed	(1) The employer does not elect the employers’ liability coverage.	Gunner Fogle	gunnerfogle@hotmail.com	Myself	Corydon	Wayne	IA	Jeremy Fogle	Erika Fogle	Signed
1574	2023-04-14 13:57	Anonymous (not verified)	94.188.205.166	Nickolas Giebelstein	Proprietorship	1942 DIXWELL ST DAVENPORT IOWA 52802	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-14	Nickolas Giebelstein	nickolasgiebelstein@gmail.com	Davenport	Scott	Iowa	Jeremy Francois	Shane Nicholson	Signed	(1) The employer does not elect the employers’ liability coverage.	Nickolas Giebelstein	nickolasgiebelstein@gmail.com	Self	Davenport	Scott	Iowa	Jeremy Francois	Shane Nicholson	Signed
1417	2023-01-11 08:55	Anonymous (not verified)	174.235.209.245	Standard Insulation Company, LLC	Limited Liability Company	1066 Prairieview Ave., 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.	2023-01-11	Mitchell Simonson	standard.insulation@outlook.com	Van Meter	Madison	IA	Jeremy Smith	Sue Sherman	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Simonson	standard.insulation@outlook.com	Owner	Van Meter	Madison	IA	Jeremy Smith	Sue Sherman	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
1443	2023-02-07 10:05	Anonymous (not verified)	166.181.84.211	Leaf home solutions	Limited Liability Company	1595 Georgetown rd Hudson Ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-07	Dean Martells	dn.mardesconstruction@gmail.com	Laporte city	Benton	Ia	Jeromia wilson	Todd mcknees	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Yurko	byurko@leacome.com	Recruiter	Hudson	Summit	Ohio	Brian mako	Mat kaulig	Signed
911	2022-02-11 19:58	Anonymous (not verified)	166.181.81.90	Legacy Taxi	Limited Liability Company	2006 E Lincoln Way Suite 2 Ames IA 50010	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-11	Megan Zogg	sctlegacy@gmail.com	Boone	Boone	IA	Jerri Ecord	Sharon Iron	Signed	(1) The employer does not elect the employers’ liability coverage.	Legacy Taxi	sctlegacy@gmail.com	Owner	Boone	Boone	IA	Jerri Ecord	Sharon Iron	Signed
1368	2022-11-11 11:58	Anonymous (not verified)	173.29.231.17	Marcelino Gutierrez	Proprietorship	1705 Des Moines Street, Des Moines, Iowa 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-11	Marcelino Gutierrez	lifestylefloors20@gmail.com	Des Moines	Polk	Iowa	Jerry Downing	Ashley Temple	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcelino Gutierrez	Lifestylefloors20@gmail.com	owner	Des Moines	Polk	Iowa	Jerry Downing	Ashley Downing	Signed
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
297	2020-10-30 10:43	Anonymous (not verified)	216.51.132.207	Kregel Farm Partnership	Limited Liability Partnership	30392 Garber RD Guttenberg, IA 52052	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-08	Travis Kregel	TRAVIS.KREGEL@GMAIL.COM	Garber	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Kregel	TRAVIS.KREGEL@GMAIL.COM	owner	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed
298	2020-10-30 10:45	Anonymous (not verified)	216.51.132.207	Kregel Farm Partnership LLP	Limited Liability Partnership	30392 Garber RD Guttenberg, IA 52052	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-08	Gary Kregel	TRAVIS.KREGEL@GMAIL.COM	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Kregel	TRAVIS.KREGEL@GMAIL.COM	same	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed
299	2020-10-30 10:47	Anonymous (not verified)	216.51.132.207	Kregel Farm Partnership LLP	Limited Liability Partnership	30392 Garber RD Guttenberg, IA 52052	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-09	Darlene Kregel	TRAVIS.KREGEL@GMAIL.COM	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Darlene Kregel	TRAVIS.KREGEL@GMAIL.COM	owner	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed
300	2020-10-30 10:51	Anonymous (not verified)	216.51.132.207	Joe Kann & Luke Kann	Partnership	32256 Leaf Rd Guttenberg IA 52052	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-28	Joe Kann	kannbros1895@gmail.com	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Joe Kann	kannbros1895@gmail.com	owner	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed
301	2020-10-30 10:53	Anonymous (not verified)	216.51.132.207	Joe Kann & Luke Kann	Partnership	32256 Leaf Rd Guttenberg IA 52052	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-27	Luke Kann	kannbros1895@gmail.com	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke Kann	kannbros1895@gmail.com	owner	Guttenberg	Clayton	Iowa	Jerry J Rochford	Nicole L Parker	Signed
1930	2023-12-01 10:20	Anonymous (not verified)	94.188.207.227	TriCounty Enterprises/ DeNeve Construction	Limited Liability Company	5527 Crane Lane NE Cedar Rapids,IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Walker	Linn	Iowa	Jerry Wiltsey	Robert Null	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Worker	Walker	Iowa	Iowa	Jerry Wiltsey	Robert Null	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
1076	2022-04-28 13:14	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	James Van Ginkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	self	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1077	2022-04-28 13:16	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Bonnie VanGinkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	owner	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1504	2023-03-07 18:38	Anonymous (not verified)	94.188.207.227	Mathias Heating & Cooling	Limited Liability Company	1449 19th Pl West Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-07	Justin Mathias	emathiasj@gmail.com	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mathias	emathiasj@gmail.com	Member	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	Signed
1459	2023-02-16 09:07	Anonymous (not verified)	94.188.205.166	Lakerats	Limited Liability Company	112 W Court Winterset IA 50273	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-05	Kyra Moore	kyra@novushomemortgage.com	Urbandale	Polk	Iowa	Jessica Anderson	Easton Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyra Moore	kyra@novushomemortgage.com	Owner	Urbandale	Polk	Iowa	Jessica Anderson	Easton Anderson	Signed
2048	2024-02-16 07:42	Anonymous (not verified)	94.188.207.224	Alexandra Machedon LLC	Proprietorship	319 N Western Street Stuart, IA 50250	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-16	Alexandra Machedon	ali@alimachedon.com	Stuart	USA	Iowa	Jessica Cash	Vicki Collins	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexandra Machedon	ali@alimachedon.com	Self	Stuart	US	IA	Jessi Cash	Vicki Collins	Signed
1882	2023-10-27 10:40	Anonymous (not verified)	94.188.205.166	Ron's SIding and Construction	Proprietorship	6097 26th Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2025-02-02	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronnie Heggebo	heggebojessica@yahoo.com	self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed
1883	2023-10-27 10:49	Anonymous (not verified)	94.188.207.228	Ron's SIding and Construction	Proprietorship	6097 26th Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-27	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Heggebo	heggebojessica@yahoo.com	Self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed
1027	2022-04-01 16:00	Anonymous (not verified)	75.162.62.199	Modern Carpentry Concepts	Limited Liability Company	2012 Ammann Dr. Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-01	Drew Hoffman	d.s.hoffman14@gmail.com	Adel	Dallas	Iowa	Jessica Hoffman	Warren Holder	Signed	(1) The employer does not elect the employers’ liability coverage.	Drew Hoffman	d.s.hoffman14@gmail.com	Same Person	Adel	Dallas	Iowa	Jessica Hoffman	Warren Holder	Signed
1656	2023-05-22 11:48	Anonymous (not verified)	94.188.205.169	Cesar Arroyo	Proprietorship	2207 Lisa Drive, 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.	2022-04-18	Cesar Arroyo	office.seamlesspros@icloud.com	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed	(1) The employer does not elect the employers’ liability coverage.	Cesar Arroyo	office.seamlesspros@icloud.com	Self	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed
1658	2023-05-23 09:56	Anonymous (not verified)	94.188.205.168	M&D Webster Construction Inc	Proprietorship	1012 Creek Street 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.	2022-03-28	David Gomez	office.seamlesspros@icloud.com	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed	(1) The employer does not elect the employers’ liability coverage.	David Gomez	office.seamlesspros@icloud.com	Self	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	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
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
71	2020-02-21 05:24	Anonymous (not verified)	70.100.107.197	CRS Inc.	Proprietorship	1442 3rd Ave SW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-20	Monica Christensen	monicalchristensen@gmail.com	Belmond	Wright	Iowa	Jessica Tempus	Dawn Butler	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Christensen	monicalchristensen@gmail.com	Consultant	Belmond	Iowa	United States	Dawn Butler	Jessica Tempus	Signed
1972	2024-01-02 14:19	Anonymous (not verified)	94.188.205.174	Parker Trucking LLC	Limited Liability Company	1507 Greene Street Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Michael Craig Parker	mcparker31@msn.com	Adel	Dallas	Iowa	Jessie Rynearson	Melisha Rynearson	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Parker	mcparker31@msn.com	Owner/Memeber	Adel	Dallas	IA	Jessie Rynearson	Melishia Rynearson	Signed
2217	2024-05-09 14:28	Anonymous (not verified)	94.188.207.224	Emmanual A Sanchez Chavez	Proprietorship	7301 Fleur Dr, Lot 10, Des Moines, 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.	2024-05-09	Emmanuel A Sanchez Chaves	alexsanchw3@gmail.com	Des Moines	Polk	Iowa	Jesus Garcia	Fabion Dalgato	Signed	(1) The employer does not elect the employers’ liability coverage.	Emmanuel A Sanchez Chavez	alexsanchw3@gmail.com	Person	Des Moines	Polk	Iowa	Jesus Garcia	Fabion Dalgato	Signed
1986	2024-01-16 12:18	Anonymous (not verified)	94.188.207.229	Wasabi Urbandale LLC	Limited Liability Company	2965 Se Timberline dr , Waukee , Iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Enjinzheng	jimmyzheng1573@gmail.com	Waukee	Dallas	Iowa	Jie Li	Yingnazheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Enjin zheng	jimmyzheng1573@gmail.com	Owner	Waukee	Dallas	Iowa	Jie Li	Yingna zheng	Signed
1987	2024-01-16 12:35	Anonymous (not verified)	94.188.207.229	Wasabi urbandale LLc	Limited Liability Company	12509 Townsend Ava, Urbandale, IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Wen Zheng	jenna18841002@hotmail.com	Urbandale	Dallas	Iowa	Jie Li	Yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Wen Zheng	jenna18841002@hotmail.com	Owner	Urbandale	Dallas	Iowas	Jie Li	Yingna zheng	Signed
114	2020-04-08 10:51	Anonymous (not verified)	167.142.107.216	1959	Proprietorship	601 Country Club 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.	2020-03-23	Timothy Alan Pottebaum	tpottebaum@nethtc.net	SHELDON	O'Brien	Iowa	Jill Boerta	Kris Schoo	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Alan Pottebaum	tpottebaum@nethtc.net	owner	SHELDON	O'brien	Iowa	Jill Boerta	Kris Schoo	Signed
1423	2023-01-16 14:03	Anonymous (not verified)	173.224.19.200	Hoofin-It	Proprietorship	86148 537th Ave. Plainview, NE 68769	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-16	Chase Terrill	terrill365@gmail.com	Pierce	Pierce	Nebraska	Jim Aschoff	Calan List	Signed	(1) The employer does not elect the employers’ liability coverage.	Cole Aschoff	aschoff_2@icloud.com	Co-Owner	Plainview	Pierce	Nebraska	Jim Aschoff	Calan List	Signed
1953	2023-12-12 15:38	Anonymous (not verified)	94.188.207.226	Ryan Gideon	Proprietorship	9320 Elmcrest Dr Norwalk, Ia 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-12	Ryan Gideon	rgid8403@gmail.com	Norwalk	Warren	IA	Jim Lane	Jim Lane	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Gideon	rgid8403@gmail.com	Owner	Norwalk	Warren	IA	jim Lane	Jim Lane	Signed
1294	2022-09-04 18:09	Anonymous (not verified)	38.121.112.25	Cabinets and Closets by Design LLC	Limited Liability Company	18409 250th Street, Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-04	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	COUNCIL BLUFFS	IA	United States	Jim Sietsema	Jeff Deramcy	Signed	(1) The employer does not elect the employers’ liability coverage.	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	self	COUNCIL BLUFFS	IA	United States	TIMOTHY SLOBODNIK	TIMOTHY SLOBODNIK	Signed
1414	2023-01-07 22:14	Anonymous (not verified)	38.121.112.25	Cabinets and Closets by Design LLC	Proprietorship	18409 250th Street, 430	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-07	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	COUNCIL BLUFFS	IA	United States	Jim Sietsema	Jeff Deramcy	Signed	(1) The employer does not elect the employers’ liability coverage.	TIMOTHY SLOBODNIK	cabinetsandclosetsbydesign@gmail.com	self	COUNCIL BLUFFS	IA	United States	TIMOTHY SLOBODNIK	TIMOTHY SLOBODNIK	Signed
404	2021-02-16 13:30	Anonymous (not verified)	174.198.79.179	Topline Painting llc	Limited Liability Company	1603 e 32nd st Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-16	Michael nunez	toplinepaintingiowa@gmail.com	Des Moines	Polk	Iowa	Jimmy nunez	Jose Nunez	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael nunez	toplinepaintingiowa@gmail.com	Owner	Des moines	Polk	Iowa	Jimmy nunez	Jose nunez	Signed

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