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:
1104	2022-05-16 13:00	Anonymous (not verified)	65.144.174.26	Medrano Flooring LLC	Limited Liability Company	8186 Harbach Blvd Apt 1, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-16	Joel Medrano	medranojoel397@gmail.com	Clive	Polk	Iowa	Ana Leon	Jesus Maldonado	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Medrano	medranojoel397@gmail.com	Self	Clive	Polk	Iowa	Ana Leon	Jesus Maldonado	Signed
1991	2024-01-17 00:34	Anonymous (not verified)	94.188.207.223	Wasabi urbandale llc	Limited Liability Company	7115 Ridgedale ct, Johnston,IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-17	Wenhui chen	michaelchen@wasabidsm.com	Johnston	Polk	Iowa	Yilian lin	Ji jie jie	Signed	(1) The employer does not elect the employers’ liability coverage.	Wenhui chen	michaelchen@wasabidsm.com	Owner	Johnston	Polk	Iowa	Yilian lin	Ji jie jie	Signed
163	2020-05-20 11:58	Anonymous (not verified)	173.27.1.111	David	Proprietorship	4023 E 28th st 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-20	David Ortiz	jdiconstrucction@gmail.com	Des Moines	Polk County	Iowa	Erika Olague	Jieldh Ortiz-Olague	Signed	(1) The employer does not elect the employers’ liability coverage.	David Ortiz	jdiconstrucction@gmail.com	JDI Construction	Des Moines	Polk County	Iowa	Erika Olague	Jieldh Ortiz-Olague	Signed
1037	2022-04-07 08:16	Anonymous (not verified)	104.207.27.18	SION LUTHERAN CHURCH	Proprietorship	4525 FINCH AVE LAKE MILLS, IA 50450	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-07	JANE BRUNSVOLD	janebrunsvold@yahoo.com	LAKE MILLS	WINNEBAGO	IOWA	ANDREW STENSRUD	JILL FLUGUM	Signed	(1) The employer does not elect the employers’ liability coverage.	ANDREW STENSRUD	ANDREW@STENSRUDINSURANCE.COM	INSURANCE AGENT	LAKE MILLS	WINNEBAGO	IOWA	JANE BRUNSVOLD	JILL FLUGUM	Signed
336	2020-12-11 11:55	Anonymous (not verified)	173.16.197.72	A Metro Snow Removal And Lawn Care	Limited Liability Company	6436 Washington Ave Windsor Heights, Iowa 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-11	Jeff Lamp Sr.	jeff.lamp79@gmail.com	Windsor Height	Polk	Iowa	Rick Brown	Jill Fresh	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeff Lamp Sr.	Jeff.lamp79@gmail.com	Owner	Windsor Heights	Polk	Iowa	Rick Brown	Jill Fresh	Signed
1855	2023-09-27 12:56	Anonymous (not verified)	94.188.207.224	Lincoln Hotel Group	Limited Liability Company	9240 Andermatt Drive Suite 1	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-27	John Edward Klimpel	jklimpel@lincolnhotelgroup.com	Lincoln	Lancaster	NE	Carrie A. Fleck	Jill N. Korta	Signed	(1) The employer does not elect the employers’ liability coverage.	Brent Besch	brent.besch@marshmma.com	Client	Lincoln	Nebraska	NE	Carrie A Fleck	Jill N Korta	Signed
278	2020-10-09 11:25	Anonymous (not verified)	174.243.82.229	ServTwelve7 Consulting, LLC	Limited Liability Company	1903 Elmhurst Avenue Humboldt, IA 50548	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-09	Sonya Satern	Sonya.satern@ServTwelve7.com	Humboldt	Humboldt	Iowa	Cindy Vik	Jill Westre	Signed	(1) The employer does not elect the employers’ liability coverage.	Sonya Satern	Sonya.Satern@ServTwelve7.com	self	Humboldt	Humboldt	Iowa	Cindy Vik	Jill Westre	Signed
1953	2023-12-12 15:38	Anonymous (not verified)	94.188.207.226	Ryan Gideon	Proprietorship	9320 Elmcrest Dr Norwalk, Ia 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-12	Ryan Gideon	rgid8403@gmail.com	Norwalk	Warren	IA	Jim Lane	Jim Lane	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Gideon	rgid8403@gmail.com	Owner	Norwalk	Warren	IA	jim Lane	Jim Lane	Signed
1062	2022-04-20 06:46	Anonymous (not verified)	38.121.112.209	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.	2022-04-18	Timothy Slobodnik	cabinetsandclosetsbydesign@gmail.com	Council Bluffs	Pottawattamie	IA	Tom Pieper	Jim Sietsema	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Slobodnik	cabinetsandclosetsbydesign@gmail.com	self	Council Bluffs	Pottawattamie	IA	Tom Pieper	Jim Sietsema	Signed
469	2021-04-12 16:49	Anonymous (not verified)	65.103.82.36	Stice Construction	Proprietorship	13723 140th st W	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-07-22	Alex Stice	Astice17@hotmail.com	Taylor Ridge	Rock Island	IL	Ashley Stice	JIm Stice	Signed	(1) The employer does not elect the employers’ liability coverage.	Alex Stice	astice17@hotmail.com	self	taylor ridge	rock island	il	Ashley stice	Jim Stice	Signed
653	2021-09-23 15:03	Anonymous (not verified)	72.46.189.33	Feldkamp Farms Inc	Partnership	5382 170th St Sibley IA 51249	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-23	Harold P Feldkamp	joan@ellerbroekandassociates.com	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed	(1) The employer does not elect the employers’ liability coverage.	James Wade Ellerbroek Jr	WADE@ELLERBROEKANDASSOCIATES.COM	Agent only	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed
1093	2022-05-12 06:32	Anonymous (not verified)	50.80.25.116	Beast Construction LLC	Limited Liability Company	1025 O Ave NW, Cedar Rapids, IA 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-01	Catarino Martinez Alvarez - H&C Roofing LLC	handc.rconst@outlook.com	North Liberty	Johnson	Iowa	Evelyn Lagos	Edgardo Hernandez	Signed	(1) The employer does not elect the employers’ liability coverage.	Greg Saunders	Gsaunders@beastconstructioncr.com	Owner	Cedar Rapids	Linn	Iowa	Laura Sturm	Joanie Lacayo	Signed
1182	2022-07-06 13:40	Anonymous (not verified)	50.80.25.116	Beast Construction LLC	Limited Liability Company	1025 O Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-11	Gilberto Vasquez (GV Construction LLC)	Normambazquez@gmail.com	Iowa City	IA	United States	Pedro Pinto	Rafael Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Greg Saunders	gsaunders@beastconstructioncr.com	Owner	CEDAR RAPIDS	IA	United States	Laura Saunders	Joanie Lacayo	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
455	2021-03-31 13:35	Anonymous (not verified)	66.188.136.150	Cody Pazicni	Proprietorship	222 Lake Shore Dr. Simpsonville, KY 40067	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-29	Cody Pazicni	kschumacher@tricorinsurance.com	Simpsonville	Shelby	KY	Russell Masartis	Jordan Pape	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Pazicni	kschumacher@tricorinsurance.com	Same	Simpsonville	Shelby	KY	Russell Masartis	Jodan Pape	Signed
1546	2023-03-29 20:53	Anonymous (not verified)	94.188.205.175	D2 Construction LLC	Limited Liability Company	16192 Wendover Ave Madrid, Iowa 50156	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Dillon Devine	d2construction22@gmail.com	Madrid	Dallas	Iowa	Mark Devine	Jodie Gumm	Signed	(1) The employer does not elect the employers’ liability coverage.	Dillon Devine	d2construction22@gmail.com	Owner	Madrid	Dallas	Iowa	Mark Devine	Jodie Gumm	Signed
2113	2024-03-23 10:21	Anonymous (not verified)	94.188.205.166	D2 Construction	Limited Liability Company	16192 wendover ave Madrid Ia 50156	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-23	Dillon Devine	d2construction22@gmail.com	Madrid	Dallas	Iowa	Chelsey devine	Jodie Gumm	Signed	(1) The employer does not elect the employers’ liability coverage.	Dillon devine	d2construction22@gmail.com	Self	Madrid	Dallas	Iowa	Chelsey devine	Jodie gumm	Signed
1066	2022-04-22 11:17	Anonymous (not verified)	50.83.107.151	Delos Steward	Proprietorship	1310 w Main Street Marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-22	Delos Lyle Steward	LDSPlastering2020@gmail.com	Marshalltown	Marshall	Iowa	Chris Hart	Jody Steward	Signed	(1) The employer does not elect the employers’ liability coverage.	LDS Plastering	ldsplastering2020@gmail.com	Owner	Marshalltown	Marshall	Iowa	Chris Hart	Jody Steward	Signed
1955	2023-12-14 09:19	Anonymous (not verified)	94.188.207.229	Protouch snow&lawn llc	Limited Liability Company	4015 sager ave waterloo	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-14	Eric brown	brown39s@yhoo.com	Waterloo	United States	Iowa	Joe brown	Emily brown	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric brown	brown39s@yahoo.com	Self	Waterloo	United States	Iowa	Emily brown	Joe brown	Signed
416	2021-03-02 10:33	Anonymous (not verified)	173.31.147.225	TJ NAIG DBA NAIG CONSULTING	Proprietorship	PO BOX 678 ARNOLDS PARK IA 51331	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-25	TJADEN NAIG	TJADENNAIG@GMAIL.COM	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JOE LORING	Signed	(1) The employer does not elect the employers’ liability coverage.	TJADEN NAIG	TJADENNAIG@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JOE LORING	Signed
930	2022-02-20 13:24	Anonymous (not verified)	174.198.77.72	2Maros Excavating Company	Limited Liability Company	204 West First Street, Saint Donatus, Iowa 52071	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-20	Steve Maro	2marosmfg@gmail.com	Saint Donatus	Jackson	Iowa	Brenda McKenna	Joe McKenna	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Maro	2marosmfg@gmail.com	Owner	Saint Donatus	Jackson	Iowa	Brenda McKenna	Joe McKenna	Signed
2171	2024-04-22 14:09	Anonymous (not verified)	94.188.205.176	Messer's concrete cutting	Proprietorship	714 Summer 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.	2024-04-22	Joe messer	josephdmesser@gmail.com	Burlington	IA	United States	Joe messer	Joe messer	Signed	(1) The employer does not elect the employers’ liability coverage.	Joe messer	josephdmesser@gmail.com	Owner	Burlington	IA	United States	Joe messer	Joe messer	Signed
182	2020-06-11 14:18	Anonymous (not verified)	173.29.64.73	Diamond Builders of Davenport INC	Proprietorship	14358 275th St, Long grove, IA 52756	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-11	Paula Woods	paulawoods@diamond-builders.com	Long Grove	IA	United States	Colin Woods	Joe Roozeboom	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Green	tyler@porterinsuranceinc.com	Insurance Agent	Long Grove	IA	United States	Colin Woods	Joe Roozeboom	Signed
575	2021-07-14 14:01	Anonymous (not verified)	69.57.205.10	Robert W. Cantrell	Proprietorship	845 East Redwood Circle, Hanford, CA 93230	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-10	Robert Wescott Cantrell	rcr4@comcast.net	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Westcott Cantrell	rcr4@comcast.net	proprietor	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed
1224	2022-07-23 14:14	Anonymous (not verified)	69.57.205.10	Robert W. Cantrell	Proprietorship	845 East Redwood Circle, Hanford, CA 93230	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-23	Robert Wescott Cantrell	marquisaviationinc@yahoo.com	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Westcott Cantrell	marquisaviationinc@yahoo.com	proprietor	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed
482	2021-04-14 21:21	Anonymous (not verified)	98.17.35.5	K3 Recycling LLC	Limited Liability Company	14801 180th Ave, Milo, IA 50166	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-14	Charles Raymond Kappelman	charliekappelman@yahoo.com	MILO	Warren	United States	Ryan Matthew Kappelman	John Allen Bahr	Signed	(1) The employer does not elect the employers’ liability coverage.	K3 Recycling LLC	charliekappelman@yahoo.com	Co-owner	Milo	Warren	Iowa	Ryan Matthew Kappelman	John Allen Bahr	Signed
2031	2024-02-07 10:54	Anonymous (not verified)	94.188.207.224	PETER MARTENS	Proprietorship	305 4TH STREET NORTH, ALBERT CITY, IOWA 50510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	PETER KLASSEN MARTENS	pkmmartens@hotmail.com	ALBERT CITY	BUENA VISTA	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed	(1) The employer does not elect the employers’ liability coverage.	PETER KLASSEN MARTENS	pkmmartens@hotmail.com	SELF	ALBERT CITY	SAC	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed
2033	2024-02-07 11:38	Anonymous (not verified)	94.188.205.168	JENKINS CONSTRUCTION	Proprietorship	315 NORTH MAIN STREET, P.O. BOX 124, ODEBOLT, IA 51458	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	DENNIS CHARLES JENKINS	dcjmjenkins@yahoo.com	ODEBOLT	SAC	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed	(1) The employer does not elect the employers’ liability coverage.	DENNIS CHARLES JENKINS	dcjmjenkins@yahoo.com	SELF	ODEBOLT	SAC	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed
2186	2024-04-28 11:12	Anonymous (not verified)	94.188.205.168	John Martin	Proprietorship	1378 60th avenue Blue Grass 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.	2024-04-28	John D Martin	martinflooring@netzero.com	Blue Grass	Muscatine	Iowa	John D Martin	John D Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	John D Martin	martinflooring@netzero.com	Owner	Blue Grass	Muscatine	Iowa	John D Martin	John D Martin	Signed
711	2021-11-04 13:07	Anonymous (not verified)	174.216.69.18	Corey Gramowski	Proprietorship	2101 21st ST Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-04	Corey Gramowski	gramowski@windstream.net	Emmetsburg	Palo Alto	IA	Frank Kliegl	John Heddinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Gramowski	gramowski@windstream.net	Self	Emmetsburg	Palo Alto	IA	Frank Kliegl	John Heddinger	Signed
797	2021-12-15 08:01	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Kenneth Roman Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	John Kenneth Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	Linn	Iowa	Douglas James Lampe	John Kenneth Lampe	Signed
798	2021-12-15 08:03	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Jared J Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	John Kenneth Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	Linn	Iowa	Douglas James Lampe	John Kenneth Lampe	Signed
218	2020-07-27 19:24	Anonymous (not verified)	174.217.10.15	Bella Exteriors LLC	Limited Liability Company	2908 Elm St, West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-27	Nicholas Andersen	nick@rightroofing.com	West Des Moines	Polk	IA	Tasha Palacioz	John Kha	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Andersen	nickande3564@gmail.com	Self	West Des Moines	Polk	IA	Tasha Palacioz	John Kha	Signed
200	2020-07-09 10:56	Anonymous (not verified)	167.142.98.40	brian chisum	Proprietorship	168 c.r. 2007 valley view tx	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-09	brian chisum	chisum413@gmail.com	valley view	cooke	tx	lakota larson	john morland	Signed	(1) The employer does not elect the employers’ liability coverage.	brian chisum	chisum413@gmail.com	self	valley view	cooke	tx	lakota larson	john morland	Signed
14	2019-12-30 17:22	Anonymous (not verified)	173.20.51.69	Rotten Love LLC	Limited Liability Company	1101 Valentine Drive, Dubuque Iowa 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-01-01	john rettenmeier	jrettenmeier@gmail.com	dubuque	Dubuque	iowa	Carolyn Schmid	Joe Rettenmeier	Signed	(1) The employer does not elect the employers’ liability coverage.	Carolyn Schmid	jrettenmeier@gmail.com	owner	Dubuque	Dubuque	iowa	John Rettenmeier	John Rettenmeier	Signed
1726	2023-07-07 18:22	Anonymous (not verified)	94.188.205.168	D&E LLC DBA Kanesville Valley	Limited Liability Company	P.O. Box 337 Council Bluffs, IA, 51502	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Damien Joseph Shull	damienshull@gmail.com	Omaha	Douglas	Nebraska	Angela Shull	John Shull	Signed	(1) The employer does not elect the employers’ liability coverage.	Damien Joseph Shull	damienshull@gmail.com	Self	Omaha	Douglas	Nebraska	Angela Shull	John Shull	Signed
524	2021-05-17 22:41	Anonymous (not verified)	166.181.84.162	Laven Construction LLC	Limited Liability Company	4935 NE 78th Ave Bondurant, Iowa 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-17	MacKale Laven	maclaven@gmail.com	Bondurant	Polk	Iowa	John Smith	Cameron Thede	Signed	(1) The employer does not elect the employers’ liability coverage.	MacKale Laven	maclaven@gmail.com	Owner	Bondurant	Polk	Iowa	Cameron Thede	John Smith	Signed
1022	2022-03-30 15:08	Anonymous (not verified)	216.51.227.123	Elite Business Cleaning	Limited Liability Company	1350 Kennel Ct Unit C2 north liberty IA 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-30	rogelio morales ortega	info@elitebusinesscleaning.com	iowa city	johnson	Iowa	alma rosa ortega	john Spencer	Signed	(1) The employer does not elect the employers’ liability coverage.	Elite Business Cleaning	info@elitebusinesscleaning.com	Ownerr	iowa city	johnson	iowa	Alma Rosa Ortega	John Spender	Signed
1492	2023-03-03 16:09	Anonymous (not verified)	94.188.207.229	Sean Aldrich LLC	Limited Liability Company	408 n.7th st. Indianola iowa 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-03	Sean Kenneth Aldrich	sean.aldrich74@gmail.com	Indianola	Warren	Iowa	Madeline Jenelle Aldrich	John Thomas Aldrich	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Kenneth Aldrich	sean.aldrich74@gmail.com	Self	Indianola	Warren	Iowa	Madeline Jenelle Aldrich	John Thomas Aldrich	Signed
1603	2023-04-25 20:42	Anonymous (not verified)	94.188.205.174	Nursepro Staffing Agency	Limited Liability Company	8450 Hickman Rd suite A2 Clive iowa 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-04-25	Teresiah muchemi	nurseproagency@gmail.com	desmoines	polk	iowa	Teresiah Muchemi	John Waweru	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Teresiah Muchemi	nurseproagency@gmail.com	Owner	desmoines	Polk	iowa	Teresiah Muchemi	John Waweru	Signed
238	2020-08-19 13:13	Anonymous (not verified)	107.77.199.95	Southern Ag Care	Limited Liability Company	301 Hoover 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.	2020-08-19	Southern Ag Care	russ_buntyn@yahoo.com	Monroe	Ouachita	LA	Mark Buntyn	Johna Buntyn	Signed	(1) The employer does not elect the employers’ liability coverage.	Russell Buntyn	russ_buntyn@yahoo.com	Owner	Monroe	Ouachita	LA	Mark Buntyn	Johna Buntyn	Signed
547	2021-06-24 08:05	Anonymous (not verified)	97.125.169.60	Tenant Improvement Services, LLC	Limited Liability Company	3011 Justin Drive, Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-24	Josh Chiles	josh@tenantimprovementsiowa.com	Des Moines	Polk	Iowa	John Martin	Johnny Holman	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Chiles	josh@tenantimprovementsiowa.com	Member	Des Moines	Polk	Iowa	John Martin	Johnny Holman	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
1782	2023-08-04 08:04	Anonymous (not verified)	94.188.207.229	Matt Larson Construction	Limited Liability Company	1208 Hazel St. Pella, IA 50219	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-04	Matthew Mark Larson	larson-m@hotmail.com	Pella	Marion	IA	Brian Huddle	Jon E. Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon E. Miller	stmarypella@iowatelecom.net	Parish Secretary	Pella	IOWA	United States	Brian Huddle	Jon E. Miller	Signed
8	2019-12-13 12:18	Anonymous (not verified)	173.18.3.76	Knight Electric, LLC	Limited Liability Company	200 E Aurora Ave, Des Moines, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-13	Ryan Lewis	ryan@knightelectric.biz	Des Moines	Polk	Iowa	Angie Kinsey	Jon Stetzel	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Lewis	ryan@knightelectric.biz	Member/Owner	Des Moines	Polk	Iowa	Angie Kinsey	Jon Stetzel	Signed
191	2020-06-23 16:09	Anonymous (not verified)	173.18.3.76	Look At You LLC	Limited Liability Company	5545 Mills Civic Pkwy Ste 100 West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-23	Amber Keppler	keppler_ark@outlook.com	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed	(1) The employer does not elect the employers’ liability coverage.	Amber Keppler	keppler_ark@outlook.com	LLC Member	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed
124	2020-04-16 12:07	Anonymous (not verified)	96.3.180.122	Gold Rush, LLC	Limited Liability Company	1395 130TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-16	Jay Christopher Morrow	jcmorrow2@hotmail.com	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed	(1) The employer does not elect the employers’ liability coverage.	Gold Rush, LLC	jcmorrow2@gmail.com	Self	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed
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
956	2022-03-08 13:56	Anonymous (not verified)	72.13.16.196	Naprstek Media LLC	Limited Liability Company	6505 Wellington Ln, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-08	James Naprstek	jimmy@kodiakcreative.com	Dubuque	Dubuque	Iowa	Trent Hanselmann	Jonathan O'Brien	Signed	(1) The employer does not elect the employers’ liability coverage.	Cheyenne Moseley	services@e.legazoom.com	Authorized Agent	Glendale	Los Angeles	CA	Trent Hanselmann	Jonathan O'Brien	Signed
1341	2022-10-23 14:31	Anonymous (not verified)	97.127.255.147	Traver Home Improvement	Limited Liability Company	14150 110 th Ave. Davenport, IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-24	Barry S Traver	traverhomeimprovement@gmail.com	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed	(1) The employer does not elect the employers’ liability coverage.	Barry S Traver	traverhomeimprovement@gmail.com	self	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed
2164	2024-04-19 13:52	Anonymous (not verified)	94.188.205.167	RKB Designs LLC	Limited Liability Company	4333 Cedar St, Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-19	Ashley Rocca	roccafive@gmail.com	Davenport	IA	United States	Nicholas Rocca	Joni Long	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Rocca	roccafive@gmail.com	Self	Davenport	IA	United States	Nicholas Rocca	Joni Long	Signed
479	2021-04-14 14:58	Anonymous (not verified)	65.103.82.36	Aaron Smart	Limited Liability Partnership	6064 227th st. albia IA 52531	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-01	Aaron Smart	nonegiven@email.com	Albia	Monroe	IA	Emily	Jordan	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Smart	nonegiven@email.com	partner	Albia	Monroe	IA	Emily	Jordan	Signed
515	2021-05-11 15:18	Anonymous (not verified)	66.188.136.150	Odie Mitchell	Proprietorship	10441 Serenity Dr. DeMotte, IN 46310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-05	Odie Mitchell	kschumacher@tricorinsurance.com	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Odie Mitchell	kschumacher@tricorinsurance.com	Same	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed
516	2021-05-12 12:41	Anonymous (not verified)	66.188.136.150	Odie Mitchell	Proprietorship	10441 Serenity Dr. DeMotte, IN 46310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-05	Odie Mitchell	kschumacher@tricorinsurance.com	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Odie Mitchell	kschumacher@tricorinsurance.com	Same	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed
517	2021-05-12 15:08	Anonymous (not verified)	66.188.136.150	Lawrence D Todd Jr.	Proprietorship	540 Sullivan St. Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-05	Lawrence D Todd Jr.	kschumacher@tricorinsurance.com	Dubuque	Dubuque	IA	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Lawrence D Todd Jr.	kschumacher@tricorinsurance.com	Same	Dubuque	Dubuque	IA	Shuree Behr	Jordan Bass	Signed
329	2020-12-01 10:02	Anonymous (not verified)	74.84.125.43	BRAINARD ROOFING & CONSTRUCTION COMPANY	Limited Liability Company	4 South Ross 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.	2020-12-01	Cody Brainard	brainardrcc2020@gmail.com	Farmersburg	Clayton	United States	Dave Moellers	Jordan Cannon	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Brainard	brainardrcc2020@gmail.com	I am the authorized agent & employer	Farmersburg	IA	United States	Dave Moellers	Jordan Cannon	Signed
610	2021-08-18 11:15	Anonymous (not verified)	172.58.84.99	LeafFilter North LLC	Partnership	866 40th ave bettendorf iowa 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-18	Thomas R Fuller	tomstl001@yahoo.com	DAVENPORT	Iowa	Iowa	Bob phillips	Julie fuller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Regional field recruiter	Bettendorf iowa	Scott	Iowa	Warren crow	Jordan lloyd	Signed
1305	2022-09-13 14:28	Anonymous (not verified)	166.181.82.226	MarDe's construction	Limited Liability Company	5381 16th Ave la porte city ia 50651	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-13	Dean Michael John Martells	deanmartells@gmail.com	La porte city	Benton	Ia	Sonya Alfreda Mounlavong	Cameron Michael Martells	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional recruiter	Kansas city, mo	Clay	Missouri	Jordan Nisiewicz	Jordan Loyd	Signed
1339	2022-10-18 14:14	Anonymous (not verified)	97.125.41.64	Juan Buenrostro	Proprietorship	2122 E 39th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-18	Juan Buenrostro	juanjosebuenrostro@gmail.com	Des Moines	Polk	IA	Juan Buenrostro	Kelly gonzalez buenrostro	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Regional recruiter	Kansas City	Clay	Missouri	Jordan nisiewicz	Jordan loyd	Signed
1344	2022-10-25 13:09	Anonymous (not verified)	69.76.241.21	Tom Cole	Proprietorship	742 Mill St. Council, 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.	2022-10-25	Tom Cole	tcoleg1963@gmail.com	Council Bluffs, IA	Pottawattamie County, IA	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City, MO	Clay	Missouri	Jordan Nisiewicz	Jordan Loyd	Signed
1391	2022-12-12 11:13	Anonymous (not verified)	136.35.255.41	Snyder Roofing	Proprietorship	2343 ridge trail 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-12-12	Craig Snyder	snyderroofingcr@gmail.com	Cedar Rapids	Linn county	Iowa	Jordan Loyd	Charles Wood	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan Loyd	Signed
1630	2023-05-09 08:54	Anonymous (not verified)	94.188.207.225	Ronald McChane	Proprietorship	400 Lewellen dr nw, CEDAR RAPIDS, IA 52405, US	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-09	Ronald McChane	rws79213@gmail.com	Cedar Rapids	Linn	Iowa	Jordan Nisiewicz	Charles Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Iowa	Charles Woods	Jordan Loyd	Signed
1685	2023-06-12 07:21	Anonymous (not verified)	94.188.207.224	Steven Boshart	Proprietorship	2172 Scales Bend Road Northeast, North Liberty, IA 52317, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-12	Steven Boshart	sboshart1982@gmail.com	North Liberty, MO	Johnson	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan Loyd	Signed
1686	2023-06-12 07:45	Anonymous (not verified)	94.188.207.229	Robert Burman	Proprietorship	400 Lindale Dr 119 Marion, 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.	2023-06-11	Robert Burman	robertburman791@gmail.com	Marion	Linn	Iowa	Charles Wood	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan loyd	Signed
1709	2023-06-26 14:55	Anonymous (not verified)	94.188.205.177	Jeremy Pledge	Proprietorship	3310 East Washington Street, Iowa City, IA 52245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-26	Jeremy Pledge	worknoplay8@gmail.com	Iowa City, IA	Johnson County	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Woods	Jordan Loyd	Signed
1722	2023-07-06 10:57	Anonymous (not verified)	94.188.205.169	Brother’s Handyman Services LLC	Proprietorship	1270 A Avenue, Marion, IA 52302, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	Tyler Dahl	handybros39@gmail.com	Marion, IA	Linn County	Iowa	Jordan Nisiewicz	Charles Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City, MO	Johnson	Missouri	Charles Woods	Jordan Loyd	Signed
1820	2023-08-28 08:12	Anonymous (not verified)	94.188.205.177	LLAD Services LLC	Limited Liability Company	1611 Esplanade Avenue Davenport IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-28	Austin Lee Terry	austinfarrell92@gmail.com	Davenport	Scott	Iowa	Cody Dunbar	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	JNisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Cody Dunbar	Jordan Loyd	Signed
2053	2024-02-22 11:29	Anonymous (not verified)	94.188.205.166	Demir sehic	Proprietorship	4052 Lafayette 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.	2024-02-22	Demir Sehic	Demirsehic123@gamil.com	Waterloo	IA	United States	Jordan nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Recurring	Kansas city	Jackson	Mo	Demir sehic	Jordan Loyd	Signed
2169	2024-04-22 09:49	Anonymous (not verified)	94.188.205.166	Galatic Service LLC	Proprietorship	623 1st street silvis IL 61282	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-22	Marcos Gonzales	Marcosg300@yahoo.com	Silvis	Rock Island	IL	Jordan lyod	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas city	Johnson	MO	Marcos Gonzales	Jordan Lyod	Signed
1357	2022-11-03 15:06	Anonymous (not verified)	66.129.196.99	Blake Carson	Limited Liability Company	1550 plainview rd ely, IA 52227	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Blake Dennis Carson	Blake@carsondesignsco.com	Ely	Linn	iowa	Dennis Carson	Jordan Mellinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Carson	Blake@carsondesignsco.com	member/Owner	Ely	linn	iowa	Dennis Carson	Jordan Mellinger	Signed
1848	2023-09-19 10:20	Anonymous (not verified)	94.188.207.226	Josh Woodworth	Proprietorship	16405 u.s. 67 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.	2023-09-19	Josh woodworth	joshwoodworth84@live.com	milan	Rock island	Illinois	Cody dunbar	Jordan nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody dunbar	cdunbar@leaffilter.com	Install manager	moline	Rock island	illinois	Cody dunbar	Jordan nisiewic	Signed
817	2021-12-30 12:58	Anonymous (not verified)	50.80.80.37	Leaf Filter	Limited Liability Company	1595 Georgetown Road Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-30	Kenneth Van Hook	kennyvanhook1976@gmail.com	Port Byron	Rock Island	IL	Sharon Van Hook	Judy Hoffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	cdunbar@leaffilter.com	Manager	Bettendorf	Scott County	IA	Cody Dunbar	Jordan Nisiewicz	Signed
1279	2022-08-22 13:17	Anonymous (not verified)	50.83.54.168	Essex Family Construction	Limited Liability Company	290 Monmouth St SW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Niki Essex	essexfamilycontruction@outlook.com	Cedar Rapids	IA	IA	Josh Lasond	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Niki Essex	essexfamilycontruction@outlook.com	same	Cedar Rapids	Iowa	Iowa	Josh Lasond	Jordan Nisiewicz	Signed
2029	2024-02-07 09:51	Anonymous (not verified)	94.188.207.223	Jorge Llanos	Proprietorship	3304 Le Mesa Way, South Sioux City, NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	Jorge Llanos	jorge.llanos123708@gmail.com	South Sioux City	Dakota	Nebraska	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Acosta	macosta@leafhome.com	Recruiter	Sioux Falls	Minnehaha	South Dakota	Cody Dunbar	Jordan Nisiewicz	Signed
1545	2023-03-29 20:15	Anonymous (not verified)	94.188.205.176	Leaf Filter LLC	Limited Liability Company	1595 georgetown road hudson ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Benjamin Joseph Truitt	Bjt1228@yahoo.com	Springville	Linn	Iowa	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewiczi	jnisiewicz@leafhome.com	Regional field recruiter 2	Riverside	Gallatin	Montana	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed
650	2021-09-22 20:46	Anonymous (not verified)	174.198.68.116	Freedom field services	Limited Liability Company	6285 n 67 ave w baxter iowa 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
651	2021-09-22 21:05	Anonymous (not verified)	174.198.68.116	Freedom field services LLC	Limited Liability Company	6285 n 67 ave w. BAXTER IOWA 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
1052	2022-04-14 19:05	Anonymous (not verified)	140.82.187.220	McHaddy Constuction	Proprietorship	423 Railroad 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.	2022-04-14	Mick Haddeman	mick@mchaddyconstruction.com	Hudson	Iowa	United States	Linsey Jo Haddeman	Jordan Renae Haddeman	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Haddeman	mick@mchaddyconstruction.com	self	Hudson	IA	United States	Linsey Jo Haddeman	Jordan Renae Haddeman	Signed
1418	2023-01-11 10:44	Anonymous (not verified)	173.23.144.232	precision edge llc	Limited Liability Company	101 belmont st milo iowa 50116	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-10	erik reha	precisionedgecompanies@gmail.com	milo	warren	iowa	bruce wilson	jordan rhode	Signed	(1) The employer does not elect the employers’ liability coverage.	n/a	precisionedgecompanies@gmail.com	n/a	n/a	n/a	n/a	bruce wilson	jordan rhode	Signed
1465	2023-02-17 15:05	Anonymous (not verified)	94.188.207.228	Big roofing	Proprietorship	114 sw 58th dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	David Christiansen	Mattc@bigroofing515.com	Des moines	Polk	IA	STEVE BIEGHLER	Jordan walkup	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt christiansen	Mattc@bigroofing515.com	Self	Des moines	County	Ia	Steve bieghler	Jordan walkup	Signed
1633	2023-05-09 15:46	Anonymous (not verified)	94.188.205.168	Unique Painting, LLC	Partnership	2500 E. 39Th Court	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-09	Ricardo Rodriguez Perfecto	uniquepainting00@gmail.com	Des Moines	USA	IOWA	Oseas Diaz	Jorge Corona	Signed	(1) The employer does not elect the employers’ liability coverage.	Ricardo Rodriguez Perfecto	uniquepainting00@gmail.com	Vice president	Des Moines	USA	IOWA	Oseas Diaz	Jorge Corona	Signed
692	2021-10-26 14:58	Anonymous (not verified)	65.144.174.26	Jake Kenney	Proprietorship	3201 Hillsdale Dr. , Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Jacob Daniel Kenney	Jakedkenney@hotmail.com	Urbandale	Polk	Iowa	Abbey Kenney	Jory Ringler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Daniel Kenney	jakedkenney@hotmail.com	Owner	Urbandale	polk	ia	abbey kenney	jory ringler	Signed
1030	2022-04-05 06:27	Anonymous (not verified)	172.58.86.173	MR Roofing LLC	Limited Liability Company	8012 Ashridge Rd. Fort Worth, Tx 76134	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	MR Roofing LLC	mrroofing.pr@gmail.com	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Robledo	mrroofing.pr@gmail.com	Owner	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed
1960	2023-12-16 11:58	Anonymous (not verified)	94.188.207.227	Landeros Framing	Proprietorship	2418 E 37th Ct	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-16	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	owner	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed
2156	2024-04-16 17:00	Anonymous (not verified)	94.188.205.166	BONILLA STONE LLC	Limited Liability Company	3201 COLUMBIA ST DES MOINES, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-16	JAIRO JAVIER BONILLA SERRANO	jairobonilla509@gmail.com	DES MOINES	POLK	IOWA	ROCIO REYES	JOSE HERNANDEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	JAIRO JAVIER BONILLA SERRANO	jairobonilla509@gmail.com	SAME	DES MOINES	POLK	IOWA	ROCIO REYES	JOSE HERNANDEZ	Signed
703	2021-11-01 11:25	Anonymous (not verified)	65.144.174.26	G & D Tile	Proprietorship	2210 E Rose Ave Apt 9 Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-01	Gerson Mejia	gersonmejia25@icloud.com	Des Moines	Polk	Iowa	Katherine Castillo	Jose Leonardo	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerson Mejia	gersonmejia25@icloud.com	Owner	Des Moines	Polk	Iowa	Katherine Castillo	Jose Leonardo	Signed
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
1866	2023-10-11 08:17	Anonymous (not verified)	94.188.205.177	Wilson's Window Tinting	Limited Liability Company	385 South Stewart Street North Liberty, Iowa 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-07	Wilson Paiva	wilsonswindowtinting@gmail.com	North Liberty	IA	United States	John W. Helscher	Jose Omar Paz	Signed	(1) The employer does not elect the employers’ liability coverage.	Wilson Paiva	wilsonswindowtinting@gmail.com	Owner	North Liberty	IA	United States	John Helscher	Jose Omar Paz	Signed
1917	2023-11-21 12:40	Anonymous (not verified)	94.188.205.174	Ramos Painting LLC	Limited Liability Company	802 E COUNTY LINE RD #279, Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	Pedro Ramos	gcort06@gmail.com	Des Moines	Polk	Iowa	Leonel Ramos	Jose Ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Pedro Ramos	gcort06@gmail.com	Owner	Des Moines	Polk	Iowa	Leonel Ramos	Jose Ramos	Signed
69	2020-02-19 15:58	Anonymous (not verified)	198.14.241.59	MORENOS C ROOFING LLC	Limited Liability Company	2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed	(1) The employer does not elect the employers’ liability coverage.	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	OWNER	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	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
694	2021-10-26 15:30	Anonymous (not verified)	65.144.174.26	Escoto Tile	Proprietorship	6820 University Ave Windsor Heights, IA 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Salvador Escoto	escototile@gmail.com	Windsor Heights	Polk	Iowa	Claudia Veronica Ojeda Escoto	Josefina Escoto	Signed	(1) The employer does not elect the employers’ liability coverage.	Salvador Escoto	escototile@gmail.com	Owner	WINDSOR HEIGHTS	Polk	Iowa	Claudia Veronica Ojeda Escoto	Josefina Escoto	Signed
1469	2023-02-19 18:23	Anonymous (not verified)	94.188.205.169	Superior Sheet Metal LLC	Limited Liability Company	1819 MM Ave Marengo, IA 52301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-19	Adam Lynn Nielsen	adamnielsen4@yahoo.com	Marengo	Iowa	United States	Emily Jean Nielsen	Joseph Daryl Kriegel	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Lynn Nielsen	adamnielsen4@yahoo.com	Self	Marengo	Iowa	Iowa	Emily Jean Nielsen	Joseph Daryl Kriegel	Signed
746	2021-11-11 19:26	Anonymous (not verified)	166.181.87.101	Joshua Duncan	Proprietorship	2237 west high street Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-11	Joshua Duncan	Jduncan8669@gmail.com	Davenport	Scott	Iowa	Megan Ward	Joseph Duncan	Signed	(1) The employer does not elect the employers’ liability coverage.	Megan Ward	megward1986@gmail.com	Fiancé	Davenport	Scott	Iowa	Megan Ward	Joseph Duncan	Signed
233	2020-08-17 14:24	Anonymous (not verified)	165.225.0.98	Daniel L Knebel	Proprietorship	439 Carroll Blvd, Dunkerton, IA, 50626	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-17	Daniel L Knebel	knebeldan@gmail.com	Dunkerton	Black Hawk	Iowa	Carman M Knebel	Joseph E Knebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel L Knebel	knebeldan@gmail.com	Owner	Dunkerton	Black Hawk	Iowa	Carman M Knebel	Joseph E Knebel	Signed
32	2020-01-08 08:31	Anonymous (not verified)	199.120.118.90	BOBCATS LLC	Limited Liability Company	1860 505TH ST LINN GROVE 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.	2019-11-18	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	OWNER	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed
1342	2022-10-25 09:02	Anonymous (not verified)	174.240.251.79	Mahieu excavation	Proprietorship	6140 n Lincoln ave Davenport iowa 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-25	Joshua j Mahieu	ridinmytrain2@gmail.com	Davenport	Scott	Iowa	Mike Leon	Joseph Koranda	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua j Mahieu	ridinmytrain2@gmail.com	Owner	Davenport	Scott	Iowa	Mike Leon	Joseph Koranda	Signed
2006	2024-01-29 11:04	Anonymous (not verified)	94.188.207.224	Kevin Jones	Proprietorship	1500 15Th St. Milford IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	KEVIN JONES	KEVINMJONES81@GMAIL.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JOSEPH LORING	Signed	(1) The employer does not elect the employers’ liability coverage.	KEVIN JONES	KEVINMJONES81@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JOSEPH LORING	Signed
2010	2024-01-30 11:46	Anonymous (not verified)	94.188.207.230	Kevin & Jlynn Jones	Proprietorship	1500 15th St. Milford Ia 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-30	Jlynn Jones	KEVINMJONES81@GMAIL.COM	Milford	Dickinson	Iowa	Tami Klein	Joseph Loring	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin & Jlynn Jones	KEVINMJONES81@GMAIL.COM	Self	Milford	Dickinson	Iowa	Tami Klein	Joseph Loring	Signed
2060	2024-02-28 09:36	Anonymous (not verified)	94.188.207.228	BRANDON LEHNER	Proprietorship	308 SANFORD STREET ARCHER IA 51231	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-28	BRANDON LEHNER	BLEHNER302@GMAIL.COM	ARCHER	OBRIEN	IA	TAMI KLEIN	JOSEPH LORING	Signed	(1) The employer does not elect the employers’ liability coverage.	BRANDON LEHNER	BLEHNER302@GMAIL.COM	SELF	ARCHER	OBRIEN	IA	TAMI KLEIN	JOSEPH LORING	Signed
1316	2022-09-21 14:49	Anonymous (not verified)	184.81.198.17	Ellen Faye Stevenson	Proprietorship	201 Stephans st. Tiffin, Iowa 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-21	Ellen Faye Stevenson	nelle@southslope.net	Tiffin	Johnson	Iowa	Catherine Louise Nelson	Joseph Roger Titone	Signed	(1) The employer does not elect the employers’ liability coverage.	Ellen Faye Stevenson	nelle@southslope.net	myself	Tiffin	Johnson	Iowa	Catherine Louise Nelson	Joseph Roger Titone	Signed
1317	2022-09-21 15:04	Anonymous (not verified)	184.81.198.17	Mark Jagnow	Proprietorship	2174 Rohret Rd SW Oxford IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-21	Mark Allen Jagnow	Mark@Jagnow.com	Oxford	Johnson	Iowa	Catherine Louise Nelson	Joseph Roger Titone	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Allen Jagnow	Mark@jagnow.com	self	Oxford	Johnson	Iowa	Catherine Louise Nelson	Joseph Roger Titone	Signed
323	2020-11-19 10:55	Anonymous (not verified)	174.192.67.61	Connor trucking	Proprietorship	2791 270th st Dewitt 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.	2020-11-19	Richard Todd Connor	connortrucking@hotmail.com	Dewitt	Clinton	Iowa	Michelle Connor	Josh connor	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Todd Connor	connortruckin@hotmail.com	Self	Dewitt	Clinton	Iowa	Michelle Connor	Josh Connor	Signed
1241	2022-08-03 10:56	Anonymous (not verified)	72.169.80.108	Landon Henriksen	Proprietorship	35374 GARDEN AVE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-03	LANDON HENRIKSEN	HENRIKSENLK@AOL.COM	Edgewood	IA	United States	LANDON HENRIKSEN	LANDON HENRIKSEN	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	LANDON HENRIKSEN	HENRIKSENLK@AOL.COM	Same	Edgewood	IA	United States	Scott Johnson	Josh lafond	Signed
541	2021-06-15 07:04	Anonymous (not verified)	63.224.181.101	Schultes Horticulture and Landscape LLC	Limited Liability Company	1444 42nd 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.	2021-06-15	Josh Schultes	schulteshort@gmail.com	Des Moines	Iowa	United States	Josh Schultes	Josh Schultes	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Schultes	schulteshort@gmail.com	Self	Des Moines	Iowa	United States	Josh Schultes	Josh Schultes	Signed
1031	2022-04-05 06:47	Anonymous (not verified)	172.58.83.170	Aaron Soboroff	Limited Liability Company	1617 w George Washington Blvd Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Aaron P Soboroff	Treedr47@gmail.com	Davenport	Scott	Iowa	Amanda Isenberg	Josh Strother	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron P Soboroff	Treedr47@gmail.com	Owner Always Mowing	Davenport	Scott	Iowa	Amanda Isenberg	Josh Strother	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
1018	2022-03-29 15:00	Anonymous (not verified)	97.125.143.50	Modified Originals of Winterset	Limited Liability Company	128 S 3rd Ave, 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.	2022-03-29	Daniel Maiers	Modifiedoriginals.winterset@gmail.com	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Maiers	Modifiedoriginals.winterset@gmail.com	Self	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williamson	Signed
1779	2023-08-03 15:40	Anonymous (not verified)	94.188.207.224	Action Garage Builders	Limited Liability Company	1635 Kerry Lane, 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.	2023-08-03	Brady Huls	brady.cve@gmail.com	Cedar Falls	Black Hawk	Iowa	Tyler Reynolds	Joshua Carder	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Even	actiongaragebuilders@gmail.com	Owner	Jesup	Buchanan	Iowa	Tyler Reynolds	Joshua Carder	Signed
1363	2022-11-08 11:37	Anonymous (not verified)	69.76.241.21	S&M Veteran Contracting	Proprietorship	1529 E Ave NW Cedar Rapids, IA 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-08	Shane Little	smveterancontracting@gmail.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Clay	MO	Jordan Loyd	Joshua Lafond	Signed
240	2020-08-23 15:03	Anonymous (not verified)	67.45.96.12	Wellik & Sons, LLC	Limited Liability Company	1770 HWY 18, Garner, IA 50438	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-23	Robert Alan Roths	robrothsrams@yahoo.com	Garner	Hancock	Iowa	Ashley S Wellik	Joshua P. Wellik	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Paul Wellik	wellikandsons@gmail.com	contractor	Garner	Hancock	Iowa	Ashley S Wellik	Joshua P Wellik	Signed
1003	2022-03-23 13:06	Anonymous (not verified)	24.149.3.190	Thomas Wedmore	Proprietorship	200 State St, Ste 202G, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Thomas Wedmore	twedmore@phillipsstafford.com	Cedar Falls	IA	United States	Bradley Phillips	Joshua Stafford	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Wedmore	twedmore@phillipsstafford.com	Self	Reinbeck	Grundy	IA	Bradley Phillips	Joshua Stafford	Signed
1449	2023-02-11 10:37	Anonymous (not verified)	94.188.207.227	Luxury Home Improvements	Limited Liability Company	4117 Boyd 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.	2023-01-11	Luis A Hernandez	luxuryhomes.iowa@gmail.com	Des Moines	Polk	Iowa	Maria T Lopez	Josmar Hernandez	Signed	(1) The employer does not elect the employers’ liability coverage.	Luis A Hernandez	luxuryhomes.iowa@gmail.com	Self	Des Moines	Polk	Iowa	Maria T Lopez	Josmar Hernandez	Signed
1421	2023-01-13 09:43	Anonymous (not verified)	96.18.190.183	Home Base Inspection & Code Services, LLC	Limited Liability Company	3805 Ridge Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-13	Amanda Harper	amanda@hbicsvs.com	Sioux City	IA	United States	Terri Harper	Joy Brouilette	Signed	(1) The employer does not elect the employers’ liability coverage.	Amanda Harper	amanda@hbicsvs.com	self	Sioux City	IA	United States	Terri Harper	Joy Brouillette	Signed
596	2021-08-04 10:48	Anonymous (not verified)	184.80.177.137	Down Home Decor Inc	Proprietorship	1021 2nd Ave SE Ste 200 Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-04	Steve Knipper	jheims@english-insurance.com	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed
757	2021-11-19 15:11	Anonymous (not verified)	184.80.177.137	Upper Room, LLC	Limited Liability Company	1314 9th St SE -Dyersville, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-19	DeAnne M McCarraher	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville, IA	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
758	2021-11-19 15:12	Anonymous (not verified)	184.80.177.137	Upper Room, LLC	Limited Liability Company	1314 9th St SE - Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-19	Keith McCarraher	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
1239	2022-08-02 10:53	Anonymous (not verified)	184.80.177.137	Jamie Ingle, DBA Jamie's Little Sunflowers	Proprietorship	7155 Columbus St - New Vienna, IA 52065	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-02	Jamie Ingle	jheims@english-insurance.com	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	dparsons@english-insurance.com	self	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
1703	2023-06-23 08:58	Anonymous (not verified)	94.188.205.175	Then & Kramer Construction, Inc	Partnership	P.O. Box 283 - Epworth, IA 52045	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Shannon Kramer	dparsons@english-insurance.com	Epworth	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	dparsons@english-insurance.com	self	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed
1704	2023-06-23 09:00	Anonymous (not verified)	94.188.205.166	THen & Kramer Construcion, Inc.	Partnership	P.O. Box 283 - Epworth, IA 52045	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Dakota Kramer	dparsons@english-insurance.com	Epworth,	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	dparsons@english-insurance.com	self	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed
1757	2023-07-20 14:45	Anonymous (not verified)	94.188.207.230	Lee Steffen	Proprietorship	608 3rd Street NE, Farley, IA 52046	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-20	Lee Steffen	lee.steffen22@icloud.com	Farley	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Lee Steffen	lee.steffen22@icloud.com	Self	Farley	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
21	2020-01-01 18:16	Anonymous (not verified)	72.35.186.80	Jerry Arnold	Proprietorship	1426 25th St, Humeston, IA 50123	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Jerry Arnold	LLArnold62@gmail.com	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Arnold	LLArnold62@gmail.com	Self	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed
1204	2022-07-14 11:59	Anonymous (not verified)	107.1.252.41	International Drywall LLC.	Limited Liability Company	108 N 4th 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.	2022-07-14	Victoria G Cervantes	vic8.cervantes@gmail.com	Marshalltown	IA	United States	Rodrigo Rodriguez	Juan Cervantes	Signed	(1) The employer does not elect the employers’ liability coverage.	Victoria G Cervantes	Vic8.cervantes@gmail.com	Self	Marshalltown	IA	United States	Rodrigo Rodriguez	Juan Cervantes	Signed
1228	2022-07-26 10:06	Anonymous (not verified)	173.23.93.3	Gaytan Framing LLC	Limited Liability Company	2418 East 37th Court	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-26	Jose Gaytan	jose1988.jg8@gmail.com	Des Moines	Polk	United States	CARLA C. GAYTAN	Juan Franco	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Gaytan	jose1988.jg8@gmail.com	self	Des Moines	IA	United States	CARLA C. GAYTAN	Juan franco	Signed
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
1858	2023-10-03 13:29	Anonymous (not verified)	94.188.207.223	Quad city drywall Solutions LLC	Limited Liability Company	5804 n thornwood ave Davenport iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-03	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Davenport	Scott	Iowa	Natalia Ann Montalvo	Juan Portela	Signed	(1) The employer does not elect the employers’ liability coverage.	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Owner	Davenport	Scott	Iowa	Natalia Montalvo	Juan Portela	Signed
1063	2022-04-21 08:23	Anonymous (not verified)	207.155.112.81	Prudenterra, LLC	Limited Liability Company	65584 260th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-04-21	Luke Robert Gran	luke@prudenterra.com	Nevada	Story	Iowa	Michael Joseph Coverdale	Judy Rae Coverdale	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Luke Robert Gran	luke@prudenterra.com	Self	Nevada	Story	Iowa	Michael Joseph Coverdale	Judy Rae Coverdale	Signed
663	2021-10-04 09:45	Anonymous (not verified)	166.181.80.1	Matthew Winters	Proprietorship	9220 Summit Dr Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-04	Matthew Winters	mattwinters55@gmail.com	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Winters	mattwinters55@gmail.com	Self	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed
1346	2022-10-26 11:54	Anonymous (not verified)	172.86.53.114	Iowa Reconstruction Services llc	Limited Liability Company	2612 E Quarry Rd, Waterloo iowa 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-26	Scott A Hambly	Iowareconsvcs@yahoo.com	Waterloo	Black hawk	Iowa	Roger Turner	Judy Turner	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Hambly	Iowareconsvcs@yahoo.com	Self	Waterloo	Black hawk	Iowa	Roger Turner	Judy Turner	Signed
94	2020-03-18 13:18	Anonymous (not verified)	174.243.114.80	Sogard Excavating	Limited Liability Company	2374 380th St, Jewell, IA 50130	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-18	Jon A Sogard	jsogard22@gmail.com	Jewell	Hamilton	IA	Fallon Sogard	Julee Lund	Signed	(1) The employer does not elect the employers’ liability coverage.	Sogard Excavating LLC	jsogard22@gmail.com	owner	Jewell	Hamilton	IA	Fallon Sogard	Julee Lund	Signed
234	2020-08-18 09:13	Anonymous (not verified)	67.55.224.208	Anthony Keahi dba Hawaiian Handyman	Proprietorship	928 8th Ave SE, Sioux Center, IA 51250-2502	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-17	Anthony Keahi	hhkeahi@gmail.com	Sioux Center	Sioux	Iowa	Kyle Blankers	Julia Huisman	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Keahi	hhkeahi@gmail.com	Self - sole proprietorship	Sioux Center	Sioux	Iowa	Kyle Blankers	Julia Huisman	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
1175	2022-07-05 07:56	Anonymous (not verified)	64.251.168.116	Daniel Alan Valburg	Proprietorship	27656 SD Hwy 44	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Dan A Valburg	agflyer620@gwtc.net	White River	Mellette	SD	George Ludvic	Julie Ludvik	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Alan Valburg	agflyer620@gwtc.net	proprieter	White River	mellette	SD	George Ludvik	Julie Ludvik	Signed
1176	2022-07-05 08:08	Anonymous (not verified)	64.251.168.116	Lucky Dude	Proprietorship	27656 SD Hwy 44 WHITE RIVER SD 57579	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Lucky Dude	agflyer620@gwtc.net	White River	Mellette	SD	George Ludvik	Julie Ludvik	Signed	(1) The employer does not elect the employers’ liability coverage.	Lucky Dude	agflyer620@gwtc.net	proprietor	White River	mellette	SD	George Ludvik	Julie Ludvik	Signed
1939	2023-12-05 14:32	Anonymous (not verified)	94.188.207.229	PJ Trucking Unlimited LLC	Limited Liability Company	2617 380th 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.	2023-12-05	Peggy Jensen	pegandhalj@gmail.com	Farragut	US	IA	Darlene	Julie Ann Marshsll	Signed	(1) The employer does not elect the employers’ liability coverage.	Peggy Jensen	pegandhalj@gmail.com	self	Farragut	US	IA	Darlene Carpenter	Julie Marshall	Signed
1017	2022-03-29 14:53	Anonymous (not verified)	208.81.192.69	Wapsie Valley Insulation, LLC	Limited Liability Company	1180 110th Street Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Lester Kauffman	bookkeeping@robertseddy.com	Fairbank	Buchanan	Iowa	Sarah Van Buren	Julie Ohl	Signed	(1) The employer does not elect the employers’ liability coverage.	Lester Kauffman	bookeeping@robertseddy.com	Same	Fairbank	Buchanan	Iowa	Sarah Van Buren	Julie Ohl	Signed
1842	2023-09-14 14:08	Anonymous (not verified)	94.188.205.174	RM Construction	Limited Liability Company	1623 120th Street, Hazleton, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-14	Roy Miller	roymiller@aol.com	Hazleton	Buchanan	Iowa	Steve Frost	Julie Schick	Signed	(1) The employer does not elect the employers’ liability coverage.	Roy Miller	roymiller@aol.com	self	Hazleton	Buchanan	Iowa	Steve Frost	Julie Schick	Signed
1048	2022-04-14 14:17	Anonymous (not verified)	208.38.229.255	Mean Green Lawn Care	Limited Liability Company	2628 W 59th st Davenport 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.	2022-04-14	Anthony mccash	meangreenlawncare20@gmail.com	Davenport	Scott	Iowa	Clarissa Oliva	Julie Thornman	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony McCash	meangreenlawncare20@gmail.com	Owner	Davenport	Scott	Iowa	Clarissa Oliva	Julie Thornman	Signed
1069	2022-04-26 08:39	Anonymous (not verified)	174.198.72.171	GR Roofing	Proprietorship	802 E County Line Rd Lot 137, Des Moines, Ia 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Eleazar Guzman-Rios	emmanuelgscop.1425@gmail.com	Des Moines	Polk	Iowa	Manny Socop	Julio Andrew	Signed	(1) The employer does not elect the employers’ liability coverage.	Eleazar Guzman-Rios	emmanuelgscop.1425@gmail.com	Owner	Des Moines	Polk	Iowa	Manny Socop	Julio Andrews	Signed
1310	2022-09-15 12:34	Anonymous (not verified)	75.162.181.22	JCC CONSTRUCTION, LLC	Limited Liability Company	823 E 22ND CT. 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.	2022-09-15	JOSE MAURICIO CARDOZA	WILSONCARDOZA1985@GMAIL.COM	DES MOINES	USA	IOWA	WILSON CARDOZA	JULIO CARDOZA	Signed	(1) The employer does not elect the employers’ liability coverage.	JOSE MAURICIO CARDOZA	WILSONCARDOZA1985@GMAIL.COM	Company Owner	Des Moines	USA	Iowa	Wilson Cardoza	Julio Cardoza	Signed
967	2022-03-11 13:41	Anonymous (not verified)	205.221.255.62	Bard Inspection Services LLC	Limited Liability Company	3207 W Van Buren Ave, Fairfield, IA 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-11	Stephanie Bard	bardfamily4@gmail.com	Fairfield	Jefferson	IA	Miranda Millhouse	Justin Millhouse	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephanie Bard	bard.inspections@gmail.com	owner	Fairfield	Jefferson	IA	Miranda Millhouse	Justin Millhouse	Signed
1444	2023-02-07 14:57	Anonymous (not verified)	173.21.126.4	Rhino Roofing	Limited Liability Company	2534 Garfield AVE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-07	Irwins Martinez	rhinoroofingsiding21@gmail.com	Des Moines	Polk	Iowa	Sara Titus	Justin Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Irwin Martinez	rhinoroofing21@gmail.com	Self	Des Moines	Polk	Iowa	Sara Titus	Justin Williams	Signed
2005	2024-01-29 08:50	Anonymous (not verified)	94.188.207.226	Laser Line Striping	Proprietorship	10572 320th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Dean Weikert	d.lineuponline@yahoo.com	Ackley	Iowa	United States	Linda Weikert	Ca	Signed	(1) The employer does not elect the employers’ liability coverage.	Kain Helmke	d.lineuponline@yahoo.com	D.lineuponline@yahoo.com	Ackley	Butler	Iowa	Linda Weikert	Kain Helmke	Signed
2176	2024-04-24 11:12	Anonymous (not verified)	94.188.205.176	Schutters Pest Control Inc.	Limited Liability Company	109 2nd Ave, Suite #2, Carbon Cliff,IL 61239	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-04	Billy Y Schutters	schutterspestcontrol@gmail.com	Bettendorf	Iowa	United States	Aidan Sammon	Kalissa Malin	Signed	(1) The employer does not elect the employers’ liability coverage.	Billy Y Schutters	schutterspestcontrol@gmail.com	Same Person	Carbon Cliff	Rock Island	Illinois	Aidan Sammon	Kalissa Malin	Signed
2011	2024-01-31 07:01	Anonymous (not verified)	94.188.205.166	Goede Mechanical	Limited Liability Company	1607 10th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-31	Don Goede	goedemechanical@gmail.com	Harlan	Shelby	Iowa	Dylan Goede	Kallie Goede	Signed	(1) The employer does not elect the employers’ liability coverage.	Don Goede	goedemechanical@gmail.com	Owner	Harlan	Shelby	Iowa	Dylan Goede	Kallie Goede	Signed
1927	2023-11-29 13:13	Anonymous (not verified)	94.188.207.228	Yaardman landscaping llc	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-29	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	Owner	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
1938	2023-12-05 11:54	Anonymous (not verified)	94.188.207.225	Genius automotive	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-05	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar james	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	None	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
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
1619	2023-04-28 11:20	Anonymous (not verified)	94.188.207.224	Hunter Flying Service, LLC	Limited Liability Company	PO Box 215 Hunter, AR 72074	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-28	Adam Towe	hunterflying@att.net	Hartselle	Morgan	Alabama	Ronnie Skinner	Karen Gifford	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Lynn Cary	hunterflying@att.net	Owner	Hunter	Woodruff	Arkansas	Ronnie Skinner	Karen Gifford	Signed
330	2020-12-03 08:11	Anonymous (not verified)	208.126.61.46	Hometown Comfort Heating & Cooling, LLC.	Limited Liability Company	1855 280th St. Webster City, Ia. 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-03	Mason Ormesher	hometowncomfortia@gmail.com	Webster City	IA	United States	Kylee Ormesher	Karen Ostrem	Signed	(1) The employer does not elect the employers’ liability coverage.	Mason Ormesher	hometowncomfortia@gmail.com	Owner	Webster City	Hamilton	Iowa	Kylee Ormesher	Karen Ostem	Signed
100	2020-03-24 15:46	Anonymous (not verified)	216.51.130.87	Lake City Electric, LLC	Limited Liability Company	113 E Main Street, Lake City, IA 51449	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-24	Lonnie R. Daisy	lcelectric@iowatelecom.net	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed	(1) The employer does not elect the employers’ liability coverage.	Lonnie R. Daisy	lcelectric@iowatelecom.net	self	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed
2042	2024-02-12 13:07	Anonymous (not verified)	94.188.205.175	Evelyn R Ventura Terrazas	Proprietorship	524 Terrence	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-12	Evelyn R Ventura Terrazas	evelynterrazas@gmail.com	Storm Lake	Buena vista	IA	Juan García Oropeza	Karen Rodríguez Pantoja	Signed	(1) The employer does not elect the employers’ liability coverage.	Evelyn R Ventura Terrazas	evelynterrazas@gmail.com	Proprietorship	Storm Lake	Buena vista	IA	Juan Garcia Oropeza	Karen Rodríguez Pantoja	Signed
1666	2023-05-28 15:57	Anonymous (not verified)	94.188.207.223	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-29	James Stock	jamese1053@gmail.com	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owner	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed
1668	2023-05-30 10:50	Anonymous (not verified)	94.188.207.230	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	James Stock	jamese1053@gmail.com	Davenport	Scott	Iowa	Ronald Lang	Karen Stock	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owener	Davenport	Scott	Iowa	Ronald Lang	Karen Walker	Signed
1669	2023-05-30 11:05	Anonymous (not verified)	94.188.207.225	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd Davenport IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	James Stock	jamese1053@gmail.com	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owner	Davenport	Scott l	Ia	Ronald Lang	Karen Walker	Signed
947	2022-03-04 11:20	Anonymous (not verified)	165.225.61.42	Timothy Peyton	Proprietorship	865 Bentley Dr Unit 23, Marion, IA, 52302	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-04	Timothy Peyton	theaton@amfam.com	Marion	Linn	IA	Terra Heaton	Kari Benore	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Peyton	theaton@amfam.com	self	Marion	Linn	IA	Terra Heaton	Kari Benore	Signed
2150	2024-04-15 12:07	Anonymous (not verified)	94.188.205.177	Todd E Holsteen	Proprietorship	16015 Hwy 99, Burlington, IA 52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-28	Todd E Holsteen	kellylanz1967@gmail.com	Burlington	IL	United States	David Steele	Kari Holsteen	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd E Holsteen	kellylanz1967@gmail.com	Self	Burlington	IA	United States	David Steele	Kari Holsteen	Signed
2183	2024-04-26 14:49	Anonymous (not verified)	94.188.205.168	Cory's Painting LLC	Limited Liability Company	Po Box 1161	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-01	Jared Birkenholz	jareddrewb@gmail.com	CEDAR FALLS	IA	United States	Colton Blue	Kari Houle	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	CEDAR FALLS	IA	United States	Colton Blue	Kari Houle	Signed
2184	2024-04-26 15:03	Anonymous (not verified)	94.188.205.166	Cory's Painting LLC	Limited Liability Company	Po Box 1161, Cedar Falls, Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-15	Joseph Abrahamson	abrahamsonjd95@gmail.com	Readlyn	Bremer	United States	Colton Blue	Kari Houle	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	Cedar Falls	Blackhawk	Iowa	Colton Blue	Kari Houle	Signed
2178	2024-04-25 10:56	Anonymous (not verified)	94.188.205.176	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	Daniel J White	danny@barerootslawn.care	Cedar Falls	Black Hawk	iowa	Kari White	James White	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Daniel J White	danny@barerootslawn.care	Owner	Cedar Falls	Black Hawk	Iowa	James White	Kari White	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
1139	2022-06-02 08:49	Anonymous (not verified)	174.198.67.34	Gentry Hardware Incorporated	Partnership	308 5th Street; Rockwell City, IA 50579	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-02	Emily Gentry	emilygentry1127@gmail.com	Rockwell City	Calhoun	IA	Ben Rand	Karie Knouf	Signed	(1) The employer does not elect the employers’ liability coverage.	Emily Gentry	emilygentry1127@gmail.com	Owner	Rockwell City	Calhoun	IA	Ben Rand	Karie Knouf	Signed
1056	2022-04-18 12:04	Anonymous (not verified)	63.152.56.49	Milo’s Construction	Limited Liability Company	8 Erobi ln Iowa city IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Adriana Celis	celisary0501@gmail.com	Iowa city	Johnson	Iowa	Arcelia Gómez	Karina Beltrán	Signed	(1) The employer does not elect the employers’ liability coverage.	Milo’s Construction	celisary0501@gmail.com	Owner	Iowa city	Johnson	Iowa	Arcelia Gómez	Karina Beltrán	Signed
1599	2023-04-25 14:38	Anonymous (not verified)	94.188.207.229	luis contreras	Proprietorship	433 8th 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.	2023-04-25	luis contreras	luisayala781@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	luis contreras	luisayala781@gmail.com	N/A	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed
1600	2023-04-25 14:38	Anonymous (not verified)	94.188.207.223	martin garcia	Proprietorship	219 austin st sw cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-25	martin garcia ayala	martingarcia2100@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	martin garcia ayala	martingarcia2100@gmail.com	na	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed
1601	2023-04-25 14:38	Anonymous (not verified)	94.188.207.230	francisco garcia	Proprietorship	388 lesley ln ne	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-25	franscisco garcia	frasicohinojosa@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	francisco garcia	frasicohinojosa@gmail.com	N/A	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed
929	2022-02-18 09:18	Anonymous (not verified)	174.198.74.217	LA Painting LLC	Limited Liability Company	6460 Merle Hay Rd unit 222 Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-18	Adolfo Rodriguez Afanador	adolforodriguez11@yahoo.com	Johnston	Polk	Iowa	Esequiel Rodriguez	Karina Valdez	Signed	(1) The employer does not elect the employers’ liability coverage.	Adolfo Rodriguez Afanador	adolforodriguez11@yahoo.com	Owner	Johnston	Polk	Iowa	Esequiel Rodriguez	Karina Valdez	Signed
506	2021-05-10 09:29	Anonymous (not verified)	199.102.211.129	Nathan J Hurst LLC DBA J&K Construction	Limited Liability Company	3598 Orchard Rd. Osage, IA 50461	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-10	Nathan J Hurst	jkconstructionjake@yahoo.com	Osage	Mitchell	Iowa	Breanna Fox	Karl Herman	Signed	(1) The employer does not elect the employers’ liability coverage.	Breanna Fox	jkconstructionjake@yahoo.com	Office Manager	Osage	Mithell	Iowa	Nathan J Hurst	Karl F Herman	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
1392	2022-12-12 11:55	Anonymous (not verified)	173.215.8.119	Jones OD PLLC	Limited Liability Company	17792 538th St Griswold, IA 51535	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-08	Travis Preston Jones	jonesodpllc@gmail.com	Griswold	Pottawattamie	Iowa	Kirk Douglas Lantz	Karla Kay Lantz	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Preston Jones	jonesodpllc@gmail.com	Officer	Griswold	Pottawattamie	Iowa	Kirk Douglas Lantz	Karla Kay Lantz	Signed
1617	2023-04-28 08:26	Anonymous (not verified)	94.188.207.230	JD Transport	Limited Liability Company	24940 247th ave Princeton Iowa 52768	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-28	Jacob Dies	jacobdiestransport@gmail.com	Princeton	Scott	Iowa	Eric Dies	Karri Dies	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Dies	Jacobdiestransport@gmail.com	Self	Princeton	Scott	Iowa	Eric Dies	Karri Dies	Signed
1899	2023-11-09 16:55	Anonymous (not verified)	94.188.207.227	Factory Services	Limited Liability Company	2444 Elm Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-09	Mark Farrell	markfa12@yahoo.com	Fort Dodge	Webster	Iowa	Heather Farrell	Karson Farrell	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Farrell	markfa12@yahoo.com	Owner	Fort Dodge	Webster	Iowa	Heather Farrell	Karson12	Signed
2199	2024-05-03 13:27	Anonymous (not verified)	94.188.207.228	Polar Delights LLC DBA Twists Ice Cream	Limited Liability Company	110 S 9th Ave 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.	2024-05-03	Anna Kokity	amkokity@gmail.com	Moline	Rock Island	IL	Ashley Schwien	Kasey Lange	Signed	(1) The employer does not elect the employers’ liability coverage.	Anna Kokity	amkokity@gmail.com	self	Moline	Rock Island	IL	Ashley Schwien	Kasey Lange	Signed
1786	2023-08-07 05:08	Anonymous (not verified)	94.188.205.169	Ph Construction Limited Liability Company	Limited Liability Company	2643 Beaver Ave Suite 105 Des Moines Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-07	Patricia Ann Hook	patricia.diverseconstruction@gmail.com	Des Moines	United States	United States	Allen W Butts	Kate Ridge	Signed	(1) The employer does not elect the employers’ liability coverage.	Patricia Ann Hook	patricia.diverseconstruction@gmail.com	Self - Owner	Des Moines	United States	Iowa	Allen W Butts	Kate Ridge	Signed
222	2020-08-03 16:16	Anonymous (not verified)	204.98.109.114	Norval Craig Michael	Proprietorship	640 NE 47th Place, Des Moines, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-20	Norval Craig Michael	accounts@dickersonmechanical.com	Des Moines	Polk	Iowa	Lisa Linnette Booher	Kathryn Lou Dickerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Nornal Craig Michael	accounts@dickersonmechanical.com	Self Employeed - Sole Proprietor	Des Moines	Polk	Iowa	Lisa Linnette Booher	Kathryn Lou Dickerson	Signed
2120	2024-03-27 15:31	Anonymous (not verified)	94.188.205.169	Dustin pleshe	Proprietorship	6855 woodland ave unit 505	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-27	Dustin Pleshe	dustinjpleshe@gmail.com	WEST DES MOINES	Iowa	United States	Kasey Cunningham	Kathy Cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Pleshe	dustinjpleshe@gmail.com	He is me	WEST DES MOINES	Iowa	United States	Kasey cunningham	Kathy cunningham	Signed
893	2022-02-03 16:17	Anonymous (not verified)	173.30.138.148	Your Cleaning Solution LLC	Limited Liability Company	P.O. Box 176 Gilbertville IA 50634	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Tricia Olson	toyourcleaningsolution@yahoo.com	Gilbertville	Black Hawk	Ia	Michael Olson	Kathy Heilig	Signed	(1) The employer does not elect the employers’ liability coverage.	Tricia Olson	toyourcleaningsolution@yahoo.com	Same person	Gilbertville	Black Hawk	Ia	Michael Olson	Kathy Heilig	Signed
145	2020-04-30 16:09	Anonymous (not verified)	173.191.206.253	Mark Knapp	Proprietorship	11244 Linden 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.	2020-04-30	Mark A Knapp	mlmlknapp@iowatelecom.net	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Knapp	mlmlknapp@iowatelecom.net	self	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	Signed
1424	2023-01-17 17:34	Anonymous (not verified)	173.191.246.189	Jabe Ramsey	Proprietorship	216 South Park Street Osceola, IA 50213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-17	Jabe Hatfield Ramsey	jaberamsey@icloud.com	Osceola	IA	United States	Sofia Contreras	Katie Anne Carson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jabe Ramsey	jaberamsey@icloud.com	ME	Osceola	Clarke	IOWA	Sofia Contreras	Katie Anne Carson	Signed
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
1184	2022-07-06 15:10	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St. Harlan, IA 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-06	Kaylee Goshorn	shelbycountyfair@fmctc.com	Harlan	Shelby	iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Kaylee Goshorn	shelbycountyfair@fmctc.com	Board Member	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed
1185	2022-07-06 15:12	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St. Harlan, IA 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-06	Darren Goshorn	shelbycountyfair@fmctc.com	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Darren Goshorn	shelbycountyfair@fmctc.com	Board Member	Harlan	Shelby	IA	Kate Heese	Katie Petersen	Signed
1186	2022-07-06 15:49	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St., Harlan, IA 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-06	Lee Schoof	shelbycountyfair@fmctc.com	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Lee Schoof	shelbycountyfair@fmctc.com	Board Member	harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed
1187	2022-07-06 15:51	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St. Harlan, IA 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-06	Kyle Manz	shelbycountyfair@fmctc.com	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Manz	shelbycountyfair@fmctc.com	Board Member	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed
457	2021-04-04 17:35	Anonymous (not verified)	104.237.118.236	Lundt Transport, LLC	Limited Liability Company	3322 Y AVE. FAIRBANK, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-04	SAMUEL LUNDT	samuelrl1998@gmail.com	FAIRBANK	Iowa	Iowa	CYNTHIA LUNDT	KATLYN HILL	Signed	(1) The employer does not elect the employers’ liability coverage.	SAMUEL LUNDT	samuelrl1998@gmail.com	SELF	FAIRBANK	FAYETTE	Iowa	CYNTHIA LUNDT	KATLYN HILL	Signed
1087	2022-05-04 12:32	Anonymous (not verified)	67.212.117.157	Polk's Lock Service, Inc.	Limited Liability Partnership	1504 College 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.	2022-05-04	Myron Piehl	polkslockservice@gmail.com	Cedar Falls	IA	United States	Jonathon Illian	Katrina Reyerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Myron John Piehl	polkslockservice@gmail.com	owner	Cedar Falls	IA	United States	Jonathan Illian	Katrina Clair Reyerson	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

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