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:
1221	2022-07-21 13:40	Anonymous (not verified)	129.222.3.107	Barkers Handyman Express	Proprietorship	120 S Mill St Gilman, IA 50106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-22	Devin Levi Barker	devinbarker91@gmail.com	Gilman	Marshall	Iowa	Emily Anne Barker	Lloyd Owen Barker Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Devin Levi Barker	devinbarker91@gmail.com	Owner	Gilman	Marshall	IA	Emily Anne Barker	Lloyd Owen Barker Jr.	Signed
1229	2022-07-26 15:56	Anonymous (not verified)	173.31.102.238	Rai Neu Jo LLC	Limited Liability Company	957 Westwood Dr NW Cedar Rapids, Iowa 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.	2022-07-26	Craig Edward Johnson	cejohnson119@yahoo.com	Cedar Rapids	Linn	Iowa	Becky Lynn Johnson	Patricia Ann Coghlan	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Edward Johnson	cejohnson119@yahoo.com	Same person	Cedar Rapids	Linn	Iowa	Becky Lynn Johnson	Patricia Ann Coghlan	Signed
1232	2022-07-28 18:27	Anonymous (not verified)	50.83.189.149	Eagle Construction Co LLC	Limited Liability Company	1150 county line rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-28	Carlos Flores	eagleconstruciontco.865@gmail.com	Des Moines	Warren	Iowa	Morgan Conrard	Ronika Htu	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlos Flores	eagleconstruciontco.865@gmail.com	Owner	Des Moines	Warren	IA	Morgan Conrard	Ronika Htu	Signed
1233	2022-07-28 22:53	Anonymous (not verified)	166.181.84.53	Leaffilter	Limited Liability Company	3060 SE Grimes Blvd Suite 100-300, Grimes, IA 501113060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-28	Mohammed Albayati	mrcarbody.81@gmail.com	Johnston	Polk	Iowa	Tammy Decker	Waffa Albayati	Signed	(1) The employer does not elect the employers’ liability coverage.	Meghan Mcilhon	mmcilhon@leaffilter.com	Human Resources	Grimes	Polk	Iowa	Tammy Decker	Waffa Albayati	Signed
1234	2022-08-01 16:55	Anonymous (not verified)	50.80.97.166	Joshua Schumacher	Proprietorship	5801 timber creek rd 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.	2022-08-01	Josh Schumacher	amjs2003@centurylink.net	Cedar Rapids	Iowa	Iowa	Karen Meroshek	Philip McCurdy	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Schumacher	amjs2003@centurylink.net	Self	Cedar Rapids	Iowa	Iowa	Katen Meroshek	Philip McCurdy	Signed
1236	2022-08-01 20:06	Anonymous (not verified)	24.149.20.39	Jake's Insulation	Proprietorship	2020 Valley High Dr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-01	Jacob Ryan Smalley	jakersmalley@gmail.com	Cedar Falls	USA	Iowa	Emily Smalley	Ben Smalley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Ryan Smalley	jakersmalley@gmail.com	Owner	Cedar Falls	USA	Iowa	Emily Smalley	Ben Smalley	Signed
1238	2022-08-02 10:24	Anonymous (not verified)	70.96.153.153	Matthew Smith	Proprietorship	2070 Golfview Ct, Marion, IA 52302	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-02	Matthew Smith	matt.s@optionsexteriors.com	Marion	Linn	Iowa	Charlotte Rasmussen	Aus	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Smith	matt.s@optionsexteriors.com	Self/Owner	Marion	Linn	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1240	2022-08-03 09:13	Anonymous (not verified)	69.57.16.37	TRAVIS TRUCKING	Proprietorship	P.O BOX 54, CURLEW IOWA 50527	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-03	TODD TRAVIS	TODDTHEFARMET@GMAIL.COM	CURLEW	PALO ALTO	IOWA	ALEX ELBERT	KELSEY ELBERT	Signed	(1) The employer does not elect the employers’ liability coverage.	TODD TRAVIS	TODDTHEFARMET@GMAIL.COM	OWNER/SELF	CURLEW	PALO ALTO	IOWA	ALEX ELBERT	KELSEY ELBERT	Signed
1248	2022-08-09 11:29	Anonymous (not verified)	166.181.82.131	Kelly Kellogg	Proprietorship	1305 N 1st st apt 16	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-09	Kelly	Kkell0223@gmail.com	Indianola	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal flooring	workorders@shoproyalflooring.com	Employee	Urbandale	Polk	Iowa	Amy	Kelly	Signed
1249	2022-08-09 14:14	Anonymous (not verified)	166.181.82.131	Kelly Kellogg	Proprietorship	1305 N 1st st apt 16	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-09	Kelly Kellogg	Kkell0223@gmail.com	Indianola	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed	(1) The employer does not elect the employers’ liability coverage.	Kelly's Flooring	Kkell0223@gmail.com	Myself	1305 N 1st st apt 16	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed
1250	2022-08-10 09:10	Anonymous (not verified)	75.162.190.54	Merit Paint Company	Proprietorship	1629 24th St, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-10	James Edward Simpson	jaybirdsimpson40@aol.com	Des Moines	Polk	Iowa	Regan Simpson	Hudson Simpson	Signed	(1) The employer does not elect the employers’ liability coverage.	James Simpson	jaybirdsimpson40@aol.com	Owner	Des Moines	Polk	Iowa	Regan Simpson	Hudson Simpson	Signed
1251	2022-08-11 09:11	Anonymous (not verified)	174.255.1.226	Two Crew Remodeling and Maintenance	Limited Liability Partnership	11 C Ave Newhall, Iowa, 52315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-11	Trenten John Schafer	Twocrewremodeling@gmail.com	Newhall	Benton	Iowa	Joeseph Allen Alger	Glenn Mitchel Kieler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan McArtor	Mcartorjordan@gmail.com	Part owner	cedar rapids	CEDAR RAPIDS, IA (Inside) LINN	Iowa	Joeseph Allen Alger	Glenn Mitchel Kieler	Signed
1252	2022-08-12 13:11	Anonymous (not verified)	166.181.85.235	Cesar cardenas	Proprietorship	48644 roma valley dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-06	Cesar Octavio Cardenas navarrete	cesarcardenas981@gmail.com	Des moines	Polk	Iowa	Cesar cardenas navarrete	Cesar cardenas Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Cesar cardenas	cesarcardenas981@gmail.com	Myself	Des moines	Polk	Iowa	Cesar cardenas	Cesar cardenas gonzalez	Signed
1254	2022-08-14 09:00	Anonymous (not verified)	172.225.140.185	Joe Forret	Limited Liability Company	18211 270st Adel Iowa 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-14	Joseph Edward Forret	joeforret@icloud.com	Adel	Dallas	Iowa	Bre Forret	Seth Slater	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph Edward Forret	joeforret@icloud.com	None	Adel	Dallas	Iowa	Bre forret	Seth Slater	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
1262	2022-08-16 12:52	Anonymous (not verified)	74.137.151.70	Golds Custom Grading LLC	Limited Liability Company	Po Box 114 Spencer, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-16	Brad Carlson	brad_carlson@gmail.com	Spencer	Clay	Iowa	Thomas Dunn	Nancy Cassa	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Thomas Dunn	TDUNN@THOMASBRADLEYINSURANCE.COM	Agent	Madison	Dane	Wisconsin	Nancy Cassa	Brad Carlson	Signed
1263	2022-08-16 13:18	Anonymous (not verified)	70.96.153.153	Sinnott Solutions LLC	Limited Liability Company	1798 643rd Ln, Albia, IA 52531	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-16	Kyle Sinnott	kyle.s@optionsexteriors.com	Albia	Monroe County	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Sinnott	kyle.s@optionsexteriors.com	Owner/Self	Albia	Monroe	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1265	2022-08-17 11:10	Anonymous (not verified)	166.181.81.66	Balvanz Electric	Proprietorship	1517 Greenfield Dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-17	Brent Balvanz	balvanzelectric@gmail.com	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed	(1) The employer does not elect the employers’ liability coverage.	Brent Balvanz	balvanzelectric@gmail.com	Self	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed
1266	2022-08-17 11:10	Anonymous (not verified)	166.181.81.66	Balvanz Electric	Proprietorship	1517 Greenfield Dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-17	Brent Balvanz	balvanzelectric@gmail.com	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed	(1) The employer does not elect the employers’ liability coverage.	Brent Balvanz	balvanzelectric@gmail.com	Self	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed
1267	2022-08-17 14:11	Anonymous (not verified)	174.192.75.162	Elijah wyant	Proprietorship	708 1/2 w 3rd st davenport ia 52802	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-17	Elijah wyant	Aidenwyant@gmail.com	Davenport	Scott	Iowa	Jake laxton	Courtney sanders	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah wyant	Aidenwyant@gmail.com	Self	Davenport	Scott	Iowa	Jake laxton	Courtney sanders	Signed
1268	2022-08-18 15:01	Anonymous (not verified)	75.162.65.221	Furgy's Carpet	Limited Liability Company	6930 NE 56th St Lot 92, Altoona, IA 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-18	Micheal Furgison	furgy4f@gmail.com	Altoona	Polk	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	Micheal Furgison	furgy4f@gmail.com	Self	Altoona	Polk	Iowa	Randy Lacina	Laura Lacina	Signed
1270	2022-08-19 08:35	Anonymous (not verified)	75.162.65.221	Tom Wilkinson	Proprietorship	621 Depot St, Kellogg, IA 50135	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-19	Tom Wilkinson	tomwilkinson4588@yahoo.com	Kellogg	Jasper	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	Tom Wilkinson	tomwilkinson4588@yahoo.com	Self	Kellogg	Jasper	Iowa	Randy Lacina	Laura Lacina	Signed
1271	2022-08-19 08:40	Anonymous (not verified)	75.162.65.221	William Ryerson	Proprietorship	15423 Aurora Ave, Urbandale, IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-19	William Ryerson	churchgirl488@yahoo.com	Urbandale	Dallas	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	William Ryerson	churchgirl488@yahoo.com	Self	Urbandale	Dallas	Iowa	Randy Lacina	Laura Lacina	Signed
1272	2022-08-19 09:36	Anonymous (not verified)	75.162.65.221	William Jones	Limited Liability Company	1639 E 13th St Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-19	William Jones	billjones1229@yahoo.com	Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	William Jones	billjones1229@yahoo.com	Self	Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	Signed
1273	2022-08-19 10:40	Anonymous (not verified)	75.162.65.221	Robert Kilgore	Proprietorship	2404 34th St Des Moines 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.	2022-08-19	Robert Kilgore	robertkilgore1969@gmail.com	Des Moines	Polk	Iowa	Randy Lacine	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Kilgore	robertkilgore1969@gmail.com	Self	Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	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
1277	2022-08-22 08:57	Anonymous (not verified)	68.169.247.177	Andrew Betts	Proprietorship	305 3rd ave sw cascade ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Andrew Betts	dbidrywallco@gmail.com	Cascade	Dubuque	Iowa	Jamie manternach	Andy hall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Betts	dbidrywallco@gmail.com	Owner	Cascade	Iowa	United States	Jamie manternach	Andy hall	Signed
1278	2022-08-22 12:15	Anonymous (not verified)	75.162.65.221	Skyler Thayer	Proprietorship	719 34th 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.	2022-08-22	Skyler Thayer	thayerskyler@gmail.com	West Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	Skyler Thayer	thayerskyler@gmail.com	Self	West Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	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
1284	2022-08-26 08:07	Anonymous (not verified)	97.125.43.203	Sindi Merida-Alvarez dba MA Construciton LLC	Limited Liability Company	2048 Lyon St Des Moines, Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Sindi Merida-ALvarez	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Sindi Merida- ALvarez	deb@piciowa.com	selk	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
1285	2022-08-26 08:22	Anonymous (not verified)	97.125.43.203	Raul Villanueva	Proprietorship	6901 SE 14th #71	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-24	Raul Villanueva	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Raul Villanueva	deb@picowa.com	self	Des Moines	Polk	IA	Debra Stratton	Kelly Denger	Signed
1287	2022-08-30 13:11	Anonymous (not verified)	173.18.22.217	Gomez Painting	Limited Liability Company	3609 56th St Des Moines IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-30	Orlyn Gomez	orlyngomez9@gmail.com	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Orlyn Gomez	orlyngomez9@gmail.com	Owner	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed
1288	2022-08-30 16:23	Anonymous (not verified)	50.83.35.94	Black Rock Flooring LLC	Limited Liability Company	189 9th st. Marion,Ia 52302	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-30	Keith Douglas Luye Sr.	Blackrockflooriing@gmail.com	Marion	Linn	Iowa	Cari Beth Lamb	Daniel Ray Lamb	Signed	(1) The employer does not elect the employers’ liability coverage.	Keith Douglas Luye Sr.	Blackrockflooring@gmail.com	self / my own authorized agent	Marion	Linn	Iowa	Cari Beth Lamb	Daniel Ray Lamb	Signed
1293	2022-09-03 08:03	Anonymous (not verified)	50.82.244.98	MTZ Drywall	Proprietorship	1101 Eighth St, West Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-02	Richar Martinez	menace_42@icloud.com	West Des Moines	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Jenkins	jjenkins@farmersagent.com	N/A	Urbandale	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed
1296	2022-09-07 08:55	Anonymous (not verified)	67.55.155.204	Kevin Utterback II	Proprietorship	801 E Ave W. Oskaloosa, Iowa 52577	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Kevin Utterback II	mark@johnsoninsurancesales.com	Oskaloosa	Iowa	Iowa	Scott Miller	Kim Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Utterback	mark@johnsoninsurancesales.com	owner of company	Oskaloosa	Iowa	Iowa	Scott Miller	Kim Miller	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
1299	2022-09-07 14:55	Anonymous (not verified)	167.142.60.66	Harleen Trenching	Proprietorship	2066 X Ave, Madrid Iowa 50156	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Bill Harleen	sandyharleen@hotmail.com	Madrid	Boone	Iowa	Thomas H Andersen	Dustin T Andersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bill Harleen	Harleentrenching@hotmail.com	Self	Madrid	Boone	Iowa	Thomas H Andersen	Dustin T Andersen	Signed
1300	2022-09-07 16:38	Anonymous (not verified)	174.198.70.216	Phillip Phelps	Proprietorship	2900 4th St Marion, IA 52302	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Phillip Phelps	phillipphelps8732@yahoo.com	Marion	Linn	Iowa	Kaitlin Davidson	Kevin Phelps	Signed	(1) The employer does not elect the employers’ liability coverage.	Phillip Phelps	phillipphelps8732@yahoo.com	Self	Marion	Linn	Iowa	Kaitlin Davidson	Kevin Phelps	Signed
1301	2022-09-08 08:02	Anonymous (not verified)	173.23.251.188	Nickolas Andersen	Proprietorship	302 E Guthrie St Linden, IA 50146	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-08	Nickolas Duane Andersen	nickandersen8888@gmail.com	Linden	Dallas	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Nickolas Andersen	nickandersen8888@gmail.com	self	Linden	Dallas	Iowa	Tara Murphy	Mike Ryerson	Signed
1306	2022-09-13 15:50	Anonymous (not verified)	96.31.1.206	LUCIO PAINTING	Proprietorship	818 W 4TH ST SPENCER, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-06	LUCIO PENA	joel@walkerinsuranceia.com	SPENCER	CLAY	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	LUCIO PENA	joel@walkerinsuranceia.com	SELF	SPENCER	CLAY	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1307	2022-09-14 13:40	Anonymous (not verified)	216.51.227.123	elite business ckeaning	Proprietorship	1350 kennel ct unit c2 north liberty IA 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-14	rogelio morales ortega	info@elitebusinesscleaning.com	iowa city	johnson	iowa	cesar morales ortega	alma rosa perez	Signed	(1) The employer does not elect the employers’ liability coverage.	elite busibess cleaning	info@elitebusinesscleaning.com	president	north liberty	johnson	iowa	karina aguilar	jessica lee	Signed
1309	2022-09-15 09:58	Anonymous (not verified)	96.31.1.206	PATTONS POWDER COATING	Limited Liability Company	421 W MAPLE DRIVE HARTLEY IA 51346	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-15	DAVID PATTON	PATTONSPOWDERCOATING@GMAIL.COM	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	PATTONS POWDER COATING - DAVID PATTON	PATTONSPOWDERCOATING@GMAIL.COM	SELF	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	Signed
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
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
1315	2022-09-20 13:11	Anonymous (not verified)	173.17.128.203	Leaffilter	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-20	Johnny Coker	johnnycoker36@gmail.com	Altoona	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter	support@leafhome.com	Sub contractor	Grimes	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed
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
1318	2022-09-22 11:18	Anonymous (not verified)	50.82.91.213	J. Thompson Builders, LLC	Limited Liability Company	5291 Stoney Creek Ct. Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-22	Christopher Jacob Von Arx	cjvonarx@hotmail.com	Van Wert IA	Decatur IA	Iowa	Christina Viehauser	Jeremy Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Christina Viehauser	christina@jthompsonbuilders.com	Office Help	Johnston Ia	Polk	IA	Chris Von Arx	Jeremy Thompson	Signed
1321	2022-09-26 08:16	Anonymous (not verified)	204.141.215.159	Leaf filter	Limited Liability Company	615 J Ave NE Cedar Rapids, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-26	Dustin Hansen	dhansen0925@gmail.com	Marion	Linn	Iowa	Audrianna Cleveland	Trevor Frondle	Signed	(1) The employer does not elect the employers’ liability coverage.	Leaf filter	sewell@leafhome.com	N/a	Cedar rapids	Linn	Iowa	N/a	N/a	Signed
1322	2022-09-27 11:31	Anonymous (not verified)	96.31.4.134	Owens Inspection Services	Limited Liability Company	598 2nd Street SE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-01	Alexander Patrick Owe s	ap_owens_14@yahoo.com	Hospers	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Patrick Owens	dpowens@premieronline.net	Owner	Sioux Center	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed
1323	2022-09-28 22:45	Anonymous (not verified)	74.51.212.66	OUTDOOR MODERN CONCEPTS LLC	Limited Liability Company	2520 RIVER MEADOWS DR., DES MOINES, IA, 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-28	CHRISTIAN RUBIO	RUBIOCH39@GMAIL.COM	DES MOINES	POLK	IOWA	AMANDA DUPRE	DARCI CLARK	Signed	(1) The employer does not elect the employers’ liability coverage.	JENNIFER B. CHAVEZ-RIVERA	JENNIFER.CHAVEZ-RIVERA@BROWNWINICK.COM	ATTORNEY	DES MOINES	POLK	IOWA	AMANDA DUPRE	DARCI CLARK	Signed
1325	2022-10-02 20:07	Anonymous (not verified)	50.80.107.101	Hanson Custom Cleanup and Removal LLC	Limited Liability Company	1221 Fleur Dr. Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-02	Jason Jacob Hanson	jasonhanson1985@gmail.com	Waterloo	Blackhawk	Iowa	Cindy Shreve	Jacob Ring	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Hanson	jasonhanson1985@gmail.com	Self	Waterloo	Blackhawk	Iowa	Cindy Shreve	Jacob Ring	Signed
1326	2022-10-04 10:27	Anonymous (not verified)	70.96.153.153	Bright Fame Inc	Limited Liability Company	2185 NW 149th St, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-04	Robert Ferguson	robert@optionsexteriors.com	Clive	Dallas	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Ferguson	robert@optionsexteriors.com	Owner/Self	Clive	Dallas	Iosa	Charlotte Rasmussen	Austin Miller	Signed
1327	2022-10-06 12:23	Anonymous (not verified)	71.39.227.238	RICK OBEREMBT	Proprietorship	1702 SYCAMORE ST, DALLAS CNETER, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-05	RICK OBEREMBT	werock83@gmail.com	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK OBEREMBT	werock83@gmail.com	SELF	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed
1328	2022-10-07 22:45	Anonymous (not verified)	50.82.178.112	Compass Commercial Services LLC	Limited Liability Company	1950 Boyson road, Hiawatha, Ia 52233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-07	Patrick Roland	mastershineservices@gmail.com	Cedar Rapids	Linn	Iowa	Aubrey Hantz	Brenna Trinkle	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Fortanini	bfontanini@compassbuilt.com	Project Manager	Hiawatha	Linn	Iowa	Aubrey Hantz	Brenna Trinkle	Signed
1329	2022-10-10 10:55	Anonymous (not verified)	173.25.222.69	Eli's	Limited Liability Company	931 S Van Buren St Iowa City, Iowa 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-10	Elijah Ortiz	eortiz15@gmail.com	Iowa City	Johnson	Iowa	Erica Mason	Bryan Horrell	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah Ortiz	eortiz15@gmail.com	Proprietor	Iowa City	Johnson	Iowa	Erica Mason	Bryan Horrell	Signed
1332	2022-10-12 20:44	Anonymous (not verified)	209.252.174.114	Nelson Tile	Proprietorship	300 Shetland Dr. N.W. 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.	2022-10-12	Bruce Allen Nelson	sherylnelson15@yahoo.com	Cedar Rapids	Linn	Iowa	Sheryl Marie Nelson	Roger Eugene Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce Allen Nelson	sherylnelson@yahoo.com	Owner,operator / same	Cedar Rapids	Linn	Iowa	Sheryl Marie Nelson	Roger Eugene Nelson	Signed
1334	2022-10-14 08:28	Anonymous (not verified)	67.212.98.135	Verbraken's New Look Painting & Decorating	Proprietorship	147 Barryington Dr. Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-14	Donald Verbraken	verbptg@aol.com	Waterloo	Black Hawk	Iowa	Cody Stoppel	Rusty Donnelly	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Verbraken	verbptg@aol.com	Owner	Waterloo	Black Hawk	Iowa	Cody Stoppel	Rusty Donnelly	Signed
1335	2022-10-17 11:32	Anonymous (not verified)	71.39.227.238	PELZER AG LLC	Limited Liability Company	16864 280TH ST, REDFIELD, IA 50233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-17	MATT PELZER	MPELZERFARMS@GMAIL.COM	REDFIELD	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT PELZER	MPELZERFARMS@GMAIL.COM	PRESIDENT	REDFIELD	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed
1337	2022-10-17 13:07	Anonymous (not verified)	173.23.251.188	Dr. Dom Home Repair LLC	Limited Liability Company	503 Cedar Ave, Woodward IA. 50276	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-17	Dominique Forest	drdomhomerepair@gmail.com	Woodward	Dallas	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dominique L Forest	drdomhomerepair@gmail.com	Owner/operator	Woodward	Dallas	Iowa	Tara Murphy	Marc Badeaux	Signed
1338	2022-10-17 15:53	Anonymous (not verified)	74.84.121.206	Mark Mitchell	Proprietorship	P O Box 38	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-15	Mark Mitchell	darrele@ciains.biz	New Albion	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Mitchell	darrele@ciains.biz	Self	New Albion	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed
1340	2022-10-18 17:03	Anonymous (not verified)	166.181.89.97	Stevens mobile welding services LLC	Limited Liability Company	5645 se 56th st. Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-18	Daniel Robert Stephens	dannystephens303@gmail.com	Carlisle	Polk	Iowa	Nikita Marie Knapp	Stacy Robin Stephens	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Robert Stephens	dannystephens303@gmail.com	Owner	Carlisle	Polk	Iowa	Nikita Marie Knapp	Stacy Robin Stephens	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
1343	2022-10-25 11:25	Anonymous (not verified)	97.125.43.203	Midwest Pro Construction LLC	Limited Liability Company	1000 SE 11th St Apt 3202	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-17	Laura Garcia	deb@piciowa.com	Grimes	polk	Iowa	Debra Stratton	Kenneth Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura Garcia	deb@piciowa.com	self	Grimes	Polk	Iowa	Debra Stratton	Kenneth Stratton	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
1345	2022-10-25 15:25	Anonymous (not verified)	166.181.82.169	Estling Junk and Garbage Removal	Limited Liability Company	660 West Main Street Apt.5	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-10-25	Jacob Steven Estling	JacobEstling1@gmail.com	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jacob Steven Estling	jacobestling1@gmail.com	Owner	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed
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
1351	2022-10-31 16:36	Anonymous (not verified)	75.231.74.186	Spencer C Nash LLC	Limited Liability Company	4233 Pineview Dr NE, Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-31	Spencer Nash	spencer@optionsexteriors.com	Cedar Rapids	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Spencer Nash	spencer@optionsexteriors.com	Owner/Self	Cedar Rapids	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1354	2022-11-01 05:31	Anonymous (not verified)	75.162.229.216	Brad Sommers Construction, LLC.	Limited Liability Company	23653 N Ave, Dallas Center, Iowa 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-31	Brad Sommers	Bsconst1@gmail.com	Dallas Center	Dallas	Iowa	Ben Sommers	Keith Winey	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Sommers	Bsconst1@gmail.com	owner	Dallas Center	Dallas	Iowa	Ben Sommers	Keith Winey	Signed
1355	2022-11-01 11:06	Anonymous (not verified)	23.252.149.120	Randy J. Hackenmiller dba Hackenmiller Trucking	Proprietorship	606 Grain Millers Dr. PO Box 125, St. Ansgar, IA 50472-0125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-01	Randy J. Hackenmiller	randhack@myomnitel.com	St. Ansgar	Mitchell	Iowa	Kent A. Wilder	Rebecca L. Dobson	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy J. Hackenmiller	randhack@myomnitel.com	Self	St. Ansgar	Mitchell	Iowa	Kent A. Wilder	Rebecca L. Dobson	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
1358	2022-11-03 23:03	Anonymous (not verified)	172.86.32.251	LeafFilter North LLC	Limited Liability Company	1020 James Drive Suite A \| Hartland, WI 53209	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-03	Aaron Bensinger	guttershereandnow@outlook.com	Marion	Linn	Iowa	Silvena Cammareri	Aaron Bensinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Bensinger	guttershereandnow@outlook.com	Self	Marion	Linn	Iowa	Aaron Bensinger	Silvena Cammareri	Signed
1359	2022-11-04 10:48	Anonymous (not verified)	173.18.22.217	Lewis Enterprises	Limited Liability Company	2723 Witmer Street Des Moines Ia 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-04	Corey Lewis	coreyboy1990@gmail.com	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Lewis	coreyboy1990@gmail.com	Owner	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed
1362	2022-11-08 08:36	Anonymous (not verified)	157.52.56.205	Martin Clip & Trim LLC	Proprietorship	Box 383 Urbana Iowa 52345	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-08	Armin Martin	arminbonnie@aol.com	Urbana	Benton	Iowa	Melissa Stieferman	Christin Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Armin Martin	arminbonnie@aol.com	Self	Urbana	Benton	Iowa	Melissa Stieferman	Christin Martin	Signed
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
1365	2022-11-09 15:42	Anonymous (not verified)	173.189.165.11	Todd Nelson DBA: TSTR Custom Woodworking	Proprietorship	625 West Sovers St, Solon, IA 52333	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-09	Todd Nelson	tstr4040@gmail.com	Solon	Johnson	Iowa	Jeff Bair-Agent	Ryan Hajek	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd Nelson	tstr4040@gmail.com	Owner/Manager	Solon	Johnson	IA	Jeff Bair	Ryan Hajek	Signed
1367	2022-11-11 11:06	Anonymous (not verified)	173.29.231.17	Sosa Flooring	Proprietorship	2310 NE 16TH Ankeny, Iowa 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-11	Zeferino Alcantara Sosa	sunnysosa@aol.com	Ankeny	Polk	Iowa	Ashley Temple	Sunny Sosa	Signed	(1) The employer does not elect the employers’ liability coverage.	Zeferino Alcantara Sosa	sunnysosa@aol.com	OWNER	Ankeny	Polk	Iowa	Ashley Temple	Sunny Sosa	Signed
1368	2022-11-11 11:58	Anonymous (not verified)	173.29.231.17	Marcelino Gutierrez	Proprietorship	1705 Des Moines Street, Des Moines, Iowa 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-11	Marcelino Gutierrez	lifestylefloors20@gmail.com	Des Moines	Polk	Iowa	Jerry Downing	Ashley Temple	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcelino Gutierrez	Lifestylefloors20@gmail.com	owner	Des Moines	Polk	Iowa	Jerry Downing	Ashley Downing	Signed
1369	2022-11-11 13:02	Anonymous (not verified)	173.29.231.17	Salvador Cardenas	Limited Liability Company	5206 SE 31st Street, Des Moines, Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-11	Salvador Cardenas	salvadorcardenas16@icloud.com	Des Moines	Polk	Iowa	Omar Gonzalez	Omar Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Salvador Cardenas	salvadorcardenas16@icloud.com	Owner	Des Moines	Polk	Iowa	Omar Gonzalez	Omar Gonzalez	Signed
1374	2022-11-17 14:33	Anonymous (not verified)	72.106.129.202	Cowman Consulting and Construction LLC	Limited Liability Company	740 NE Horizon Dr, Waukee IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-17	Khalid Cowman	khalidcowman1@gmail.com	Waukee	Dalls	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Khalid Cowman	khalidcowman1@gmail.com	Self/Owner	Waukee	Dallas	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1376	2022-11-18 10:22	Anonymous (not verified)	166.181.87.119	Ashley Heffernen	Proprietorship	4009 Majestic Ct NE Cedar Rapids Iowa 52411	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-18	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Self	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed
1377	2022-11-21 13:06	Anonymous (not verified)	166.181.84.102	Leaf home solutions	Proprietorship	1595 George Town 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.	2022-11-21	Christopher da von carpenter	chris.carpenter9595@icloud.com	Pleasant hill	Polk	Iowa	Clara Francis carpenter	Thrinadh gutta	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher da von carpenter	chris.carpenter9595@icloud.com	Self	Pleasant hill	Polk	Iowa	Clara Francis carpenter	Thrinadh gutta	Signed
1379	2022-11-22 11:44	Anonymous (not verified)	166.181.89.236	365 Services LLC	Limited Liability Company	306 hayes st e hazleton iowa 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-22	Clayton marshall davis	Lcrc365@outlook.com	Hazleton	Bucanan	Iowa	Grace lilibridge	Kurt king	Signed	(1) The employer does not elect the employers’ liability coverage.	Clayton marshall davis	Lcrc365@outlook.com	Owner	Hazleton	Bucanan	Iowa	Kurt kind	Grace lilibridge	Signed
1382	2022-12-07 14:40	Anonymous (not verified)	96.31.1.206	IGL RENTAL LLC	Limited Liability Company	PO BOX 317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-25	AARON JONES	STAYBOJI@GMAIL.COM	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	AARON JONES	STAYBOJI@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1383	2022-12-07 14:42	Anonymous (not verified)	96.31.1.206	IGL RENTAL LLC	Limited Liability Company	PO BOX 317 ARNOLDS PARK IA 51331	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-25	CHAD JONES	STAYBOJI@GMAIL.COM	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHAD JONES	STAYBOJI@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1384	2022-12-08 13:11	Anonymous (not verified)	172.58.81.43	Sehic G&S, LLC.	Limited Liability Company	4201 62nd st apt 4 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.	2022-12-09	Bajro sehic	kalesija20@gmail.com	Urbandale	Polk	Iowa	N/A	N/A	Signed	(1) The employer does not elect the employers’ liability coverage.	Bajro sehic	kalesija20@gmail.com	Owner	Urbandale	Polk	Iowa	N/A	N/A	Signed
1385	2022-12-08 18:45	Anonymous (not verified)	173.26.84.6	Fansco LLC	Limited Liability Company	620 2 nd Ave SE Cresco IOWA 52136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-12-08	Arif Sheikh	Sheikha44@yahoo.com	Cresco	Howard	IOWA	Bibi Sheikh	Usman Sheikh	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Arif Sheikh	Sheikha44@yahoo.com	Relative	Henderson	Clark	Navada	Bibi Sheikh	Usman Sheikh	Signed
1386	2022-12-09 08:35	Anonymous (not verified)	173.26.84.6	Fansco LLc DBA Cresco motel	Limited Liability Company	620 2 nd Ave SE Cresco IOwa 52136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-09	Arif Sheikh	Sheikha44@yahoo.com	Cresco	Howard	IOWA	Bibi Sheikh	Usman Sheikh	Signed	(1) The employer does not elect the employers’ liability coverage.	Arif Sheikh	Sheikha44@yahoo.com	Self	CRESCO	Howard	IOWA	Bibi Sheikh	Usman Sheikh	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
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
1393	2022-12-13 12:45	Anonymous (not verified)	50.82.133.22	Ponderosa Outdoor	Limited Liability Partnership	104 Vista Dr Montezuma, Ia 50171	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-13	Daniel Deaver	ponderosaoutdoor@gmail.com	Altoona	Polk	Iowa	Faith Deaver	Jessi Perkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Deaver	ponderosaoutdoor@gmail.com	self	Altoona	Polk	Iowa	Faith Deaver	Jessi Perkins	Signed
1394	2022-12-14 14:31	Anonymous (not verified)	74.84.121.206	Benjamin Salo	Proprietorship	320 Plat St Lansing, IA 52151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-09	Benjamin Salo	benwa011@gmail.com	Lansing, Iowa	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Benjamin Salo	benwa011@gmail.com	self	Lansing	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed
1395	2022-12-15 08:02	Anonymous (not verified)	172.58.84.122	Sehic G&S, LCC	Limited Liability Company	4201 62nd st Urbandale iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-15	Bajro sehic	kalesija20@gmail.com	Urbandale	Polk	Iowa	Bajro	Bajro	Signed	(1) The employer does not elect the employers’ liability coverage.	Bajro sehic	kalesija20@gmail.com	Owner	Urbandale	Dallas	Iowa	Bajro	Bajro	Signed
1397	2022-12-21 14:05	Anonymous (not verified)	50.81.162.60	Jesse Iseminger	Proprietorship	3117 e 40th ct, Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-21	Jesse Iseminger	Jesseiseminger@gmail.com	Des Moines	Polk	Iowa	Shelly Johns	Brad Weikert	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Iseminger	Jesseiseminger@gmail.com	Self	Des Moines	Iowa	Iowa	Shelly Johns	Brad Weikert	Signed
1400	2022-12-22 10:02	Anonymous (not verified)	166.196.110.105	It's a Breeze Cleaning Service	Proprietorship	760 W 8th Ave Marion, IA 52302	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-22	Breonna Nelson	breanderson82@yahoo.com	Marion	Linn	Iowa	Tyler Nelson	Lisa Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Breonna Nelson	Breanderson82@yahoo.com	Self	Marion	Linn	IA	Tyler Nelson	Lisa Nelson	Signed
1401	2022-12-23 09:07	Anonymous (not verified)	75.162.43.221	Capital Express	Limited Liability Company	Council is Chris Blunk out of omaha NB.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-09-09	Nicholas Michelfelder	nicmichelfelder@gmail.com	8018 Valdez Circle	polk	iowa	Ted Michelfelder	lucy Sanderson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Chris Blunk	cblunk@harrislawomaha.com	None	1400 SE gateway Dr. 105	Polk	IA	Theodore Michelfelder	Rick Isacson	Signed
1403	2023-01-03 15:23	Anonymous (not verified)	173.20.50.85	Falcon Pride Properties, LLC	Limited Liability Company	1401 State Highway 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-23	D. Jay Ellis	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	D. Jay Ellis	cmins_re@mchsi.com	Owner	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1404	2023-01-03 15:26	Anonymous (not verified)	173.20.50.85	Falcon Pride Properties, LLC	Limited Liability Company	1401 State Highway 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-23	Todd Thomas	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd Thomas	cmins_re@mchsi.com	Owner	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1407	2023-01-04 13:26	Anonymous (not verified)	67.55.135.18	Duncan Customs LLC	Limited Liability Company	8857 Union Cir. Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-04	Rory Eugene Duncan	ddmusicsolutions@gmail.com	Cedar Falls	Black Hawk	Iowa	Travis Duncan	Alethea Duncan	Signed	(1) The employer does not elect the employers’ liability coverage.	Rory Duncan	ddmusicsolutions@gmail.com	self	Cedar Falls	Black Hawk	Iowa	Travis Duncan	Alethea Duncan	Signed
1410	2023-01-06 10:58	Anonymous (not verified)	173.25.103.95	Bryce Kenworthy	Proprietorship	155 NW Maple St Elkhart IA 50073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-06	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Owner	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed
1413	2023-01-06 15:15	Anonymous (not verified)	199.120.121.97	Jason Gaul	Proprietorship	1088 Ridge Lane Harlan, IA 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-06	Jason Robert Gaul	gauljasonr@gmail.com	Harlan	Shelby	Iowa	Haley Leinen	Scott Leinen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Robert Gaul	gauljasonr@gmail.com	Self	Harlan	Shelby	Iowa	Haley Leinen	Scott Leinen	Signed
1415	2023-01-09 10:50	Anonymous (not verified)	73.103.30.27	MWK Solutions, LLC	Limited Liability Company	1001 South Park St., Fairfield, IA 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-09	Michael Wayne Koch	mwkpar@gmail.com	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Wayne Koch	mwkpar@gmail.com	Self	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed
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
1419	2023-01-12 09:27	Anonymous (not verified)	71.34.173.44	Solid Solutions Caulking LLC.	Limited Liability Company	1011 N. Ankeny BLVD Po Box 216 Ankeny IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Jesse Guilford	sscaulking@yahoo.com	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Guilford	sscaulking@yahoo.com	Self	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed
1420	2023-01-12 13:42	Anonymous (not verified)	75.162.144.157	Clearer Sky	Limited Liability Company	2305 Drake Park Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-12	Osvaldo Mayorga Delgado	grae1524@gmail.com	Des Moines	Polk	Iowa	Juan Manuel Mayorga Delgado	Gloria Lorena Enamorado Guzman	Signed	(1) The employer does not elect the employers’ liability coverage.	Osvaldo Mayorga Delgado	Grae1524@gmail.com	Self	Des Moines	Polk	Iowa	Juan Manuel Mayorga Delgado	Gloria Lorena Enamorado Guzman	Signed
1422	2023-01-14 10:26	Anonymous (not verified)	71.39.227.238	Udderly Great Downtown Scoops LLC	Limited Liability Company	530 Walnut St, PO Box 251, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-09	Stephani S Jimmerson	stephjimmerson67@gmail.com	Minburn	Dallas	Iowa	Abbey Luellen	Laura Richardson	Signed	(1) The employer does not elect the employers’ liability coverage.	Don Richardson	DonR@phillipsassociatesins.net	Agent	Minburn	Dallas	Iowa	Abbey Luellen	Laura Richardson	Signed
1427	2023-01-23 10:53	Anonymous (not verified)	174.198.74.123	Landon Manfull	Proprietorship	51909 hwy 210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Landon Manfull	landonmanfull1@gmail.com	Slater	Story	Iowa	Landon Manfull	Landon Manfull	Signed	(1) The employer does not elect the employers’ liability coverage.	Landon Manfull	landonmanfull1@gmail.com	Myself	Slater	Story	Iowa	Landon Manfull	Landon Manfull	Signed
1433	2023-01-27 13:24	Anonymous (not verified)	184.97.152.214	Rwdcarpet	Proprietorship	4927 cedarbrook 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.	2023-01-27	Robert Wayne Durand iii	rwdcarpet24@gmail.com	Council bluffs	Pottawattamie	Iowa	Kitty whissinand	Kelley durand	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Wayne Durand iii	rwdcarpet24@gmail.com	Self	Council bluffs	Pottawattamie	Iowa	Kitty whissinand	Kelley Durand	Signed
1434	2023-01-31 07:12	Anonymous (not verified)	162.233.75.173	abc	Proprietorship	1122	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-31	Brian Yurko	byurko714@gmail.com	Cedar Falls	Black Hawk	Iowa	pete	re pete	Signed	(1) The employer does not elect the employers’ liability coverage.	LHE	byurko@leafhome.com	contractor	Deerfield Beach	Florida	United States	pete	re pete	Signed
1438	2023-02-03 14:23	Anonymous (not verified)	173.18.22.217	Cruz Construction Company, LLC	Proprietorship	2105 Clark Street, Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-03	Juan Canseco Cruz	jcruz2515@icloud.com	Des Moines	Polk	Iowa	Erick Schuldt	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan Conseco Cruz	jcruz2515@icloud.com	Owner	Des Moines	Polk	Iowa	Erick Schuldt	Kelly Coluzzi	Signed
1440	2023-02-06 14:24	Anonymous (not verified)	69.40.94.166	ESW CONSTRUCTION INC	Partnership	315 hIGHWAY 22, KESWICK IA 50136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-06	ROSS SIEREN	rtsieren@gmail.com	KESWICK	KEOKUK	IOWA	JULIE WHITE	REBECCA APPLEGET	Signed	(1) The employer does not elect the employers’ liability coverage.	BARBARA EDMUNDSON	barb@iowacropservice.com	agent	SIGOURNEY	KEOKUK	IOWA	JULIE WHITE	REBECCA APPLEGET	Signed
1441	2023-02-06 14:37	Anonymous (not verified)	69.40.94.166	ESW CONSTRUCTION INC	Partnership	35 HIGHWAY 22, KESWICK IA 50136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-06	JOSHUA EDMUNDSON	payten@iowacropservice.com	KESWICK	KEOKUK	IOWA	JULIE WHITE	REBECCA APPLEGET	Signed	(1) The employer does not elect the employers’ liability coverage.	BARBARA EDMUNDSON	barb@iowacropservice.com	agent	SIGOURNEY	KEOKUK	IOWA	JULIE WHITE	REBECCA APPLEGET	Signed
1442	2023-02-06 14:40	Anonymous (not verified)	69.40.94.166	ESW CONSTRUCTION INC	Partnership	315 hIGHWAY 22, KESWICK IA 50136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-06	WENDELL WILEY	rtsieren@gmail.com	BLOOMFIED	DAVIS	IOWA	JULIE WHITE	REBECCA APPLEGET	Signed	(1) The employer does not elect the employers’ liability coverage.	BARBARA EDMUNDSON	barb@iowacropservice.com	agent	SIGOURNEY	KEOKUK	IOWA	JULIE WHITE	REBECCA APPLEGET	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
1446	2023-02-08 16:49	Anonymous (not verified)	94.188.207.228	ZAHID ALI	Limited Liability Company	3245 SOUTHGATE PL SW, IOWA 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-10	ZAHID ALI	ali@americaninncid.com	CEDAR RAPIDS	USA	IOWA	ZAHID ALI	ZAHID ALI	Signed	(1) The employer does not elect the employers’ liability coverage.	ZAHID ALI	ali@americaninncid.com	self	cedar rapids	usa	iowa	ZAHID ALI	ZAHID ALI	Signed
1447	2023-02-09 16:12	Anonymous (not verified)	94.188.205.166	Ryan Klocke	Limited Liability Company	315 1st Street Templeton, IA 54163	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-09	Ryan Klocke	heidi@nextgenagsupply.com	Templeton	Carroll	Iowa	Kim Gienau	Zach Counsell	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Klocke	heidi@nexgenagsupply.com	President	Templeton	Carroll	Iowa	Kim Gienau	Zach Counsell	Signed
1448	2023-02-10 16:55	Anonymous (not verified)	94.188.205.177	Marks Nursery LLC	Limited Liability Company	15008 310th Trl, Redfield, IA 50233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-10	Susan L Jones	sljoines026@gmail.com	Redfield	Dallas	Iowa	Douglas Jones	Caitlin Zimmerman	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Richardson	DonR@phillipsassociatesins.net	Agent	Redfield	Dallas	Iowa	Douglas Zimmerman	Caitlin Zimmerman	Signed
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
1450	2023-02-11 10:59	Anonymous (not verified)	94.188.205.168	JOSE G OLIVAREZ	Limited Liability Company	1529 11TH ST DES MOINES IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-11	JOSE G OLIVAREZ	joseolivares742@gmail.com	DES MOINES	POLK	IOWA	SAMIR RAHMANOVIC	SAMIR RAHMANOVIC	Signed	(1) The employer does not elect the employers’ liability coverage.	none	joseolivares742@gmail.com	none	DES MOINES	POLK	IOWA	samir rahmanovic	samir rahmanovic	Signed
1451	2023-02-13 13:27	Anonymous (not verified)	94.188.205.168	Better Built Floors, LLC	Limited Liability Company	950 Spruce street Waukee, IA, 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-13	Bodhi Cox	betterbuiltfloors@gmail.com	waukee	dallas	iowa	Bodhi Cox	Daniel Cox	Signed	(1) The employer does not elect the employers’ liability coverage.	Bodhi Cox	betterbuiltfloors@gmail.com	i am thge owner/operator	waukee	dallas	iowa	Bodhi Cox	Daniel Cox	Signed
1452	2023-02-13 16:49	Anonymous (not verified)	94.188.207.228	The Wine Shop, LLC	Limited Liability Company	305 Main St, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-02-13	Dana Swasand	danaswasand@rocketmail.com	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Dana Swasand	danaswasand@rocketmail.com	Owner/Member	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed
1453	2023-02-14 07:19	Anonymous (not verified)	94.188.207.230	Milton Gray	Proprietorship	255 10th Ave., Marion, IA 52302, 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.	2023-02-13	Milton Gray	miltongray23@gmail.com	Marion, IA	Linn	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	MO	Charles Wood	Steven Geisler	Signed
1455	2023-02-15 11:44	Anonymous (not verified)	94.188.205.177	Bruce A. Nelson	Proprietorship	300 Shetland Dr Nw Cedar Rapids, IA 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-15	Bruce A. Nelson	sherylnelson15@yahoo.com	Cedar Rapids	Linn	Iowa	Lynn M Haigh	David Reibsamen	Signed	(1) The employer does not elect the employers’ liability coverage.	Sheryl Nelson	sherylnelson15@yahoo.com	Wife	Cedar Rapids	Linn	Iowa	Lynn M. Haigh	David Reibsamen	Signed
1457	2023-02-15 18:06	Anonymous (not verified)	94.188.205.166	Chad Cowan	Limited Liability Company	2108 Locust 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.	2023-02-15	Chad Stuart Cowan	chad@bigroofing515.com	West Des Moines	Polk	Iowa	Paul Mouw	Rob Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Cowan	rr2cw@yahoo.com	Same	West Des Moines	IA	United States	Paul Mouw	Rob Schultz	Signed
1458	2023-02-16 07:20	Anonymous (not verified)	94.188.205.167	Windsor Earth Works, dba Wells Commercial Flooring	Limited Liability Company	1442 73rd Street, 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.	2023-02-16	Timothy E Wells	wellsba1@msn.com	Windsor Heights	Polk	Iowa	Leonard Klug	Barbara Wells	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara Wells	wellsba65@gmail.com	Spouse	Windsor Heights	Polk	Iowa	Leonard Klug	Timothy Wells	Signed
1459	2023-02-16 09:07	Anonymous (not verified)	94.188.205.166	Lakerats	Limited Liability Company	112 W Court Winterset IA 50273	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-05	Kyra Moore	kyra@novushomemortgage.com	Urbandale	Polk	Iowa	Jessica Anderson	Easton Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyra Moore	kyra@novushomemortgage.com	Owner	Urbandale	Polk	Iowa	Jessica Anderson	Easton Anderson	Signed
1460	2023-02-16 12:36	Anonymous (not verified)	94.188.205.174	Certified Septic Service	Proprietorship	2121 Rodeo ave monroe iowa 50170	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-16	Justin Rozendaal	jusroz12@gmail.com	Monroe	Jasper	Iowa	Justin Rozendaal	Miranda Rozendaal	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Rozendaal	certifiedseptic@gmail.com	Self	Monroe	Jasper	Iowa	Justin Rozendaal	Miranda Rozendaal	Signed
1463	2023-02-17 14:24	Anonymous (not verified)	94.188.207.224	Matt Evans	Limited Liability Company	508 53rd Place West Des Moines, IA 50266	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	Matthew Evans	matt@bigroofing515.com	West Des Moines	Polk	Iowa	Steve Bieghler	Matt Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Evans	matt@bigroofing515.com	Self	West Des Moines	Polk	Iowa	Steve Bieghler	Matt Evans	Signed
1468	2023-02-17 16:17	Anonymous (not verified)	94.188.207.230	AJ Cook LLC	Limited Liability Company	1817 Redbud Street, 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.	2023-02-17	Alejandro Cook	alejandro.cook14@gmail.com	Norwalk	Warren	Iowa	Steve Bieghler	Nichole Bishop	Signed	(1) The employer does not elect the employers’ liability coverage.	Alejandro Cook	alejandro.cook14@gmail.com	Self	Norwalk	Warren	Iowa	Steve Bieghler	Nichole Bishop	Signed
1470	2023-02-20 08:38	Anonymous (not verified)	94.188.205.167	Level92 Screen Printing LLC	Limited Liability Company	2500 W 2nd Ave Ste 10, Indianola, IA 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Alison Vice	orders@level92.com	Indianola	Warren	Iowa	Bill Bauer	Cindy Bauer	Signed	(1) The employer does not elect the employers’ liability coverage.	Alison Vice	orders@level92.com	Partner	Indianola	Warren	Iowa	Bill Bauer	Cindy Bauer	Signed
1471	2023-02-20 10:24	Anonymous (not verified)	94.188.205.169	Vega Investments	Limited Liability Company	330 NE 72nd Street, Pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Stephanie Westrom	stephanie.westrom@microsoft.com	Pleasant Hill	Polk	Iowa	Thomas Westrom	Jean Schnake	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephanie Westrom	stephanie.westrom@microsoft.com	Owner	Pleasant Hill	Polk	Iowa	Thomas Westrom	Jean Schnake	Signed
1473	2023-02-20 15:57	Anonymous (not verified)	94.188.207.224	C & A Fox Farms LLC	Limited Liability Company	3275 valley Ave Orchard IA 50460	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Allen Fox	sales@foxfarmsllc.com	Orchard	Mitchell	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen Fox	sales@foxfarmsllc.com	self	Orchard	Mitchell	Iowa	Darrel Elsbernd	Chris Fye	Signed
1475	2023-02-21 18:42	Anonymous (not verified)	94.188.207.230	Michael Goodyk Consgtruction	Proprietorship	2392 Keokuk Drive Pella, Iowa. 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.	2023-02-20	Michael Jay Goodyk	mikegoodyk@gmail.com	Pella	Marion	Iowa	Joy Ekloffe	Rick Ekloffe	Signed	(1) The employer does not elect the employers’ liability coverage.	Gorp Edwards insurance	bwilliams@vangorpins.com	Insurance Agent	Pella	Marion	Iowa	Joy Ekloffe	Rick Ekloffe	Signed
1477	2023-02-23 11:45	Anonymous (not verified)	94.188.205.166	Earl Woods DBA Solar Solutions	Proprietorship	1328 42nd St Des Moines IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-23	Earl Woods	solarsolutions_1@msn.com	Des Moines	Polk	Iowa	Terrie Woods	Tracy Day	Signed	(1) The employer does not elect the employers’ liability coverage.	Earl Woods	solarsolutions_1@msn.com	wife	Des Moines	Polk	IA	Terrie Woods	Tracy Day	Signed
1479	2023-02-24 08:34	Anonymous (not verified)	94.188.207.229	Sedenka Excavating and Habitat	Limited Liability Partnership	204 Meadowview Drive, Lisbon, IA 52253	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-24	Trey Sedenka	SedenkaEH@gmail.com	Lisbon	Cedar	Iowa	Robert Cummings	Jayson Wallace	Signed	(1) The employer does not elect the employers’ liability coverage.	Trey Sedenka	SedenkaEH@gmail.com	Owner	Lisbon	Cedar	Iowa	Robert Cummings	Jayson Wallace	Signed
1480	2023-02-24 08:54	Anonymous (not verified)	94.188.205.176	Shear Texture	Limited Liability Company	2000 Wiley Blvd SW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-24	Wendy Kiser	kiser187@msn.com	Cedar Rapids	Linn	Iowa	Kim Erickson	Shauna Whitaker	Signed	(1) The employer does not elect the employers’ liability coverage.	Wendy Kiser	kiser187@msn.com	Self	Cedar Rapids	Linn	Iowa	Kim Erickson	Shauna Whitaker	Signed
1481	2023-02-24 12:45	Anonymous (not verified)	94.188.207.223	Molly Onken	Limited Liability Company	52480 HWY 210 Slater, IA. 50244	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Molly S Onken	mollyaols@gmail.com	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed	(1) The employer does not elect the employers’ liability coverage.	Molly S Onken	mollyaols@gmail.com	Owner	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed
1482	2023-02-24 13:57	Anonymous (not verified)	94.188.205.175	Vaughn Seeds, LLC	Limited Liability Company	5025 13th 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.	2023-02-24	Brice Jacob Vaughn	brice.vaughn1@gmail.com	La Porte Citty	Benton	Iowa	Abby Jo Rolston	Jessica Lyn McCabe	Signed	(1) The employer does not elect the employers’ liability coverage.	Abby Rolston	arolston@hagerins.net	Insured	La Porte City	Black Hawk	Iowa	Jessica Lyn McCabe	Russell Britson	Signed
1484	2023-02-25 16:42	Anonymous (not verified)	94.188.205.177	Carpenter wood shed/ rays longging	Limited Liability Company	1631 230th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-27	Raymond Carpenter	corinnafrymoyer@gmail.com	tipton	Cedar	Iowa	corinna frymoyer	Levi carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Carpenter	corinnafrymoyer@gmail.com	Self	Tipton	Cedar	Iowa	Corinna frymoyer	Levi carpenter	Signed
1487	2023-02-27 22:12	Anonymous (not verified)	94.188.207.224	Panda garden	Proprietorship	105 2nd Ave se cresco ia 52136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-10	Jing Chen	jingchen9968@gmail.com	Cresco	Howard	Iowa	Leyang Zhou	Guy Chen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jing Chen	jingchen9968@gmail.com	Self	Cresco	Howard	Iowa	Leyang zhou	Guy Chen	Signed
1489	2023-02-28 16:06	Anonymous (not verified)	94.188.207.228	Nate's Tractor LLC	Limited Liability Company	11939 birch Ave Riceville, IA 50466	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-28	Nathan Fox	nate@natestractor.com	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Fox	nate@natestractor.com	Member	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed
1490	2023-03-03 10:31	Anonymous (not verified)	94.188.205.175	Bagby Lawncar and More	Limited Liability Company	921 Pleasant Street, Des Moines IA 50309	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-03	Cory Michael Bagby	bagbylawncareandmore@gmail.com	921 Pleasant Street	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Bagby	babylawncareandmore@gmail.com	Owner	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed
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
1493	2023-03-05 22:42	Anonymous (not verified)	94.188.207.226	Wyckoff Heating and Cooling	Proprietorship	95 hwy 5 carlisle, ia 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-05	Travis Keeney	knytrav@aol.com	carlisle	warren	iowa	James Ren	Troy Keeney	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Keeney	knytrav@aol.com	Subcontractor	carlisle	warren	iowa	James Ren	Troy Keeney	Signed
1497	2023-03-07 07:37	Anonymous (not verified)	94.188.207.229	Holzworth Land Company	Limited Liability Company	1730 All State Ct Suite 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-03-07	Victor Holzworth	holzconstruction@gmail.com	West Des Moines	Polk	Iowa	Reid Tamisiea	Mariah Burgett	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Victor Holzworth	holzconstruction@gmail.com	Owner	West Des Moines	Polk	iowa	Reid Tamisea	Mariah Burgett	Signed
1499	2023-03-07 11:21	Anonymous (not verified)	94.188.205.177	Ryan Zimmerman	Proprietorship	17606 35th St Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-27	Ryan Zimmerman	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed
1501	2023-03-07 11:27	Anonymous (not verified)	94.188.205.167	Adriene Dangler	Proprietorship	2400 South Shore Dr Clear Lake, IA 50428	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Adrienne Dangler	darrele@ciains.biz	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed
1502	2023-03-07 12:40	Anonymous (not verified)	94.188.205.177	Joseph Martin	Limited Liability Company	P O Box 277 Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Joseph Martin	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Al's Roofing LLC	darrele@ciains.biz	Member	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chrus Fye	Signed
1503	2023-03-07 12:45	Anonymous (not verified)	94.188.205.177	Al's Roofing LLC	Limited Liability Company	P O Box 277 Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	John Martin	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Al's Roofing LLC	darrele@ciains.biz	agent	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed
1504	2023-03-07 18:38	Anonymous (not verified)	94.188.207.227	Mathias Heating & Cooling	Limited Liability Company	1449 19th Pl West Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-07	Justin Mathias	emathiasj@gmail.com	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mathias	emathiasj@gmail.com	Member	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	Signed
1505	2023-03-07 23:14	Anonymous (not verified)	94.188.207.229	Harbinger Consultants LLC	Limited Liability Company	2333 SW Plaza Pkwy, #324, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	Joseph French	joey@harbinger.finance	Ankeny	Polk	Iowa	Sawyer Mueller	Kenneth French	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph French	joey@harbinger.finance	Principal	Ankeny	Polk	Iowa	Sawyer Mueller	Kenneth French	Signed
1506	2023-03-08 15:12	Anonymous (not verified)	94.188.207.226	Heritage Towing LLC	Limited Liability Company	404 Sherman Ave. Ackley Iowa 50601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-08	Jeff Brass	heritagemotors17@yahoo.com	Ackley	Hardin	Iowa	Joellen Reynolds	Linzie Morris	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeff Brass	hertiagemotors17@yahoo.com	Member of LLC	Ackley	Hardin	Iowa	JoEllen Reynolds	Linzie Morris	Signed
1512	2023-03-10 09:44	Anonymous (not verified)	94.188.205.169	eliseo isai	Proprietorship	5301 SE 24th St Des Moines, IA 50320 United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-08	eliseo isai carranza perez	Misaelballeza40@gmail.com	desmoines	polk	iowa	Julio Nolvela	giovanni nolvela	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	eliseo isai carranza perez	Misaelballeza40@gmail.com	self	desmoines	polk	iowa	Julio Nolvela	giovanni nolvela	Signed
1513	2023-03-13 06:54	Anonymous (not verified)	94.188.205.169	Tyler Ankney	Proprietorship	1250 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.	2023-03-13	Tyler Ankney	T_james55@ahoo.com	Marion	Linn County	Iowa	Jordan Nisiewicz	Steve Gisler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Steve Gisler	Signed
1514	2023-03-13 10:04	Anonymous (not verified)	94.188.205.166	MMK Electric	Limited Liability Partnership	4515 84th St 84th Street Urbandale, Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-13	Travis Miller	mmk.iowa@gmail.com	Urbandale	Polk	Iowa	Elijah Kain	Marshall McKay	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Elijah Kain	Marshall McKay	Signed
1515	2023-03-13 15:04	Anonymous (not verified)	94.188.207.226	Flint Hillman	Proprietorship	1019 E 17th St, APT 16, 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.	2023-03-13	Flint Hillman	flinthillman@gmail.com	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed	(1) The employer does not elect the employers’ liability coverage.	Flint Hillman	flinthillman@gmail.com	Self	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed
1516	2023-03-14 09:00	Anonymous (not verified)	94.188.207.225	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-14	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
1517	2023-03-14 09:06	Anonymous (not verified)	94.188.207.230	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-14	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
1519	2023-03-16 09:15	Anonymous (not verified)	94.188.205.176	Frommelt Logging LLC	Limited Liability Company	109 Great River Rd. Holy Cross IA 52053	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-16	Josh Frommelt	jfrommelt1987@gmail.com	Holy Cross	Clayton	Iowa	Staci Frommelt	Mitzi Hoeger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Frommelt	jfrommelt1987@gmail.com	owner	Holy Cross	Clayton	Iowa	Staci Frommelt	Mitzi Hoeger	Signed
1520	2023-03-16 14:24	Anonymous (not verified)	94.188.205.167	MMK Electric	Partnership	4515 84th Street Urbandale, Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-16	Marshall Logan McKay	mmk.iowa@gmail.com	Des Moines	Polk	Iowa	Travis Miller	Elijah Kain	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Elijah Kain	Travis Miller	Signed
1521	2023-03-16 14:26	Anonymous (not verified)	94.188.207.229	Mmk electric	Partnership	4515 84th st Urbandale ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-16	Elijah dale kain	mmk.iowa@gmail.com	West Des moines	Polk	Iowa	Travis Lee miller	Marshall Logan McKay	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Lee miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Travis Lee miller	Marshall Logan mckay	Signed
1528	2023-03-22 10:37	Anonymous (not verified)	94.188.205.175	Uhl Cattle Company	Partnership	3329 Ozark Ave, Mapleton IA 51034	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-01	Tonya Jean Uhl	tonyajuhl@gmail.com	Mapleton	Woodbury	iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Tonya Jean Uhl	tonyajuhl@gmail.com	Owner	Mapleton	Woodbury	Iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed
1529	2023-03-22 10:40	Anonymous (not verified)	94.188.205.175	Uhl Cattle Company	Partnership	3329 Ozark Ave, Mapleton IA 51034	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-01	Troy Michael Uhl	troyuhl1224@gmail.com	Mapleton	Woodbury	Iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Tonya Jean Uhl	tonyajuhl@gmail.com	Brother	Mapleton	Woodbury	Iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed
1530	2023-03-23 16:14	Anonymous (not verified)	94.188.205.166	Los Cousins gutters	Limited Liability Company	901 sw 62nd st des moines ia 50312	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-23	Freddy Morales	1981ayoria@gmail.com	Des Moines Ia	Polk	Iowa	Denni bazan	Dionicio morales	Signed	(1) The employer does not elect the employers’ liability coverage.	Freddy Morales	1981ayoria@gmail.com	1981ayoria@gmail.com	Desmoines	Polk	Ia	Dennis Bazan	Dionicio Morales	Signed
1532	2023-03-24 18:05	Anonymous (not verified)	94.188.205.174	Crafty Dome LLC	Limited Liability Company	3524 Stonebridge Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-24	Susan Bernau	craftydome@yahoo.com	West Des Moines	Polk	Iowa	George Cummins	Linda Green	Signed	(1) The employer does not elect the employers’ liability coverage.	Susan Bernau	craftydome@yahoo.com	owner	3524 Stonebridge Rd	Polk	Iowa	George Cummins	Linda Green	Signed
1533	2023-03-25 10:24	Anonymous (not verified)	94.188.207.226	Doug Uridil	Proprietorship	616 16th Street NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-22	Doug Uridil	douguridil@gmail.com	Cedar Rapids	United States	IOWA	Heidi Vincent	Molly Coffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Uridil	douguridil@gmail.com	Self	Cedar Rapids	United status	IOWA	Heidi Vincent	Molly Kaufman	Signed
1536	2023-03-27 10:47	Anonymous (not verified)	94.188.205.174	Cecile C Knipp	Limited Liability Company	1418 Oakcrest Dr., Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-27	Cecile C Knipp	ceilknipp@gmail.com	Waterloo	Black Hawk	Iowa	Monica Robbins	Anne Betts	Signed	(1) The employer does not elect the employers’ liability coverage.	Cecile C Knipp	christinaknipp@aol.com	Self	Waterloo	Black Hawk	Iowa	Monica Robbins	Anne Betts	Signed
1538	2023-03-27 15:20	Anonymous (not verified)	94.188.205.167	Luke Woods	Limited Liability Company	1513 Burnett Station Road Central City, IA 52214	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-27	Luke James Woods	woodsmencontractingllc@gmail.com	Central City	Linn	Iowa	Keith John Woods	Heath John Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke James Woods	woodsmencontractingllc@gmail.com	same person	Central City	Linn	Iowa	Keith John Woods	Heath John Woods	Signed
1542	2023-03-29 14:43	Anonymous (not verified)	94.188.205.166	Peterson Home Improvement, LLC	Limited Liability Company	31451 510th Street Russell, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-28	Paul M Peterson	petersonhomeimprovementllc@gmail.com	Russell	Lucas	Iowa	Peggy Jo Peterson	Matthew Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Peggy Peterson	petersonhomeimprovementllc@gmail.com	Husband	Russell	Lucas	Iowa	Paul M Peterson	Matthew Peterson	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
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
1548	2023-03-30 14:18	Anonymous (not verified)	94.188.207.229	Lance Jordison	Proprietorship	2295 Nelson Ave, Fort Dodge, IA 50501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-30	Lance Jordison	jordisontrucking@gmail.com	Fort Dodge	Webster	Iowa	Ashlee Neumann	Ed Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Jordison	jordisontrucking@gmail.com	Owner	Fort Dodge	Webster	Iowa	Ashlee Neumann	Ed Smith	Signed
1550	2023-03-31 13:35	Anonymous (not verified)	94.188.205.177	Nadarevic Group LLC	Limited Liability Company	3633 NW 177th Ct, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-31	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Owner	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed
1551	2023-03-31 13:37	Anonymous (not verified)	94.188.205.176	Nadarevic Group LLC	Limited Liability Company	3633 NW 177th Ct, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-31	Nicole Nadarevic	niki@silverstonedevgroup.com	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Owner	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed
1552	2023-04-03 13:58	Anonymous (not verified)	94.188.205.168	F&I Drywall Llc	Limited Liability Company	509 Arlington Dr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-03	Fernando Garcia	Fgarcia1989.fg@gmail.com	Marshalltown	Marshall	Iowa	Gabriela Garcia	Araceli Tafolla	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Garcia	Fgarcia1989.fg@gmail.com	Self	Marshalltown	Marshall	Iowa	Gabriela Garcia	Araceli Tafolla	Signed
1554	2023-04-04 16:30	Anonymous (not verified)	94.188.205.176	House of Bean Studios	Limited Liability Company	2066 170th Street, Guthrie Center, IA 50115	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-04	Nicole Jazzmin Bean	nicolebean.studios@gmail.com	Guthrie Center	Guthrie	Iowa	Daniel Bean	Anthony Durst	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicole Jazzmin Bean	houseofbeanstudios@gmail.com	Self (Sole-proprietor LLC)	Guthrie Center	Guthrie	Iowa	Daniel Bean	Anthony Durst	Signed
1555	2023-04-05 08:03	Anonymous (not verified)	94.188.207.227	DK Motor Freight	Proprietorship	3621 Tyler Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-05	David Kirchner	dkirchner89@gmail.com	Hartley	Obrien	Iowa	Janna VanDonge	Chad Driesen	Signed	(1) The employer does not elect the employers’ liability coverage.	David Kirchner	dkirchner89@gmail.com	Self	Hartley	Iowa	United States	Janna VanDonge	Chad Driesen	Signed
1558	2023-04-06 19:15	Anonymous (not verified)	94.188.207.224	Bechler Services	Limited Liability Partnership	5244 180th Street Sibley 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.	2023-04-06	Payton Bechler	bechler.services@gmail.com	Sibley	Osceola	Iowa	Kody Koerselman	Richard Bechler	Signed	(1) The employer does not elect the employers’ liability coverage.	Payton Bechler	bechler.services@gmail.com	Owner	Sibley	Osceola	Iowa	Kody Koerselman	Richard Bechler	Signed
1559	2023-04-07 11:43	Anonymous (not verified)	94.188.205.177	Art Deco Tile and Stone	Limited Liability Company	4615 94th Pl Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-07	Edin Musinovic	edin@artdecotileandstone.com	Urbandale	Polk	Iowa	Rick Wyant	Todd Wyant	Signed	(1) The employer does not elect the employers’ liability coverage.	Edin Musinovic	edin@artdecotileandstone.com	Self	Urbandale	Polk	Iowa	Rick Wyant	Todd Wyant	Signed
1560	2023-04-07 11:47	Anonymous (not verified)	94.188.205.174	Art Deco Tile and Stone	Limited Liability Company	4615 94th Pl Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-07	Jasmin Musinovic	edin@artdecotileandstone.com	Urbandale	Polk	Iowa	Rick Wyant	Todd Wyant	Signed	(1) The employer does not elect the employers’ liability coverage.	Jasmin Musinovic	edin@artdecotileandstone.com	Self	Urbandale	Polk	Iowa	Rick Wyant	Todd Wyant	Signed
1561	2023-04-10 07:35	Anonymous (not verified)	94.188.207.227	All season gutter	Limited Liability Company	1790 187th street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-10	Shane Harold schnittjer	allseasongutter@outlook.com	Webster city	Hamilton	Iowa	Andrea Rae schnittjer	Shane Ethan schnittjer	Signed	(1) The employer does not elect the employers’ liability coverage.	Shane Harold schnittjer	allseasongutter@outlook.com	Self	Webster City	Hamilton	Iowa	Andrea Rae schnittjer	Shane Ethan schnittjer	Signed
1562	2023-04-10 07:43	Anonymous (not verified)	94.188.205.174	JB Concrete and Construction	Limited Liability Company	306 1st Ave N.W Dayton Ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-10	JaredBerglund	jaredberglund71@gmail.com	Dayton	Webster	Iowa	Travis Sonksen	Chase Haman	Signed	(1) The employer does not elect the employers’ liability coverage.	JaredBerglund	jaredberglund71@gmail.com	Owner	Dayton	Webster	Iowa	Travis Sonksen	Chase Haman	Signed
1563	2023-04-11 08:49	Anonymous (not verified)	94.188.205.168	Ibrahim Sehic	Proprietorship	4052 Lafayette Rd, Evansdale, IA 50707	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-11	Ibrahim Sehic	bacosidig@gmail.com	Evansdale, IA	Black Hawk County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Warren Crow	Signed
1564	2023-04-11 09:15	Anonymous (not verified)	94.188.205.174	Darryl Kinnard	Proprietorship	60 Miller Avenue Southwest #13, Cedar Rapids, IA 52404, 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.	2023-04-11	Darryl Kinnard	darryl186d@icloud.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	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Robert Snyder	Signed
1565	2023-04-11 09:49	Anonymous (not verified)	94.188.205.177	Leonard Moss Roofing	Proprietorship	2018 Superior Street, Webster City, Iowa 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.	2023-04-11	Leonard Moss	leonard.moss48@gmail.com	Webster City	Hamilton	Iowa	Vicky Hahne	Morgan Jensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Leonard Moss	leonard.moss48@gmail.com	Same	Webster City	Hamilton	Iowa	Vicky Hahne	Morgan Jensen	Signed
1566	2023-04-12 08:40	Anonymous (not verified)	94.188.205.169	Sabokwigura Jonathan	Proprietorship	1613 12th Avenue Southeast, Cedar Rapids, IA 52401, 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.	2023-04-12	Sabokwigura Jonathan	nzobojo@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	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Robert Snyder	Signed
1567	2023-04-12 10:01	Anonymous (not verified)	94.188.205.177	Hearts on fire llc	Limited Liability Partnership	931 14th Ave Se Altoona Iowa 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-12	Matt Moffet	dsm@fibrenew.com	Altoona	Polk	Iowa	Jason McDowell	Mike Wennekamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Moffet	dam@fibrenew.com	Owner	Altoona	Polk	Iowa	Jason McDowell	Mike Wennekamp	Signed
1568	2023-04-12 10:46	Anonymous (not verified)	94.188.205.175	Daniel gramowski	Limited Liability Company	2835 raccoon street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-12	Daniel gramowski	oneanddoneroofing@gmail.com	Des moines	Polk	Iowa	Paige gramowski	Cole smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel gramowski	oneanddoneroofing@gmail.com	Owner	Des Moines	Polk	Iowa	Cole smith	Paige gramowski	Signed
1573	2023-04-14 13:43	Anonymous (not verified)	94.188.205.167	Jaxon Kressley	Proprietorship	954 Boston Way, #12, Corralville, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-14	Jaxon Kressley	jaxon@optionsexteriors.com	Corralville	Johnson	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaxon Kressley	jaxon@optionsexteriors.com	Owner/Self	Corralville	Johnson	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1574	2023-04-14 13:57	Anonymous (not verified)	94.188.205.166	Nickolas Giebelstein	Proprietorship	1942 DIXWELL ST DAVENPORT IOWA 52802	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-14	Nickolas Giebelstein	nickolasgiebelstein@gmail.com	Davenport	Scott	Iowa	Jeremy Francois	Shane Nicholson	Signed	(1) The employer does not elect the employers’ liability coverage.	Nickolas Giebelstein	nickolasgiebelstein@gmail.com	Self	Davenport	Scott	Iowa	Jeremy Francois	Shane Nicholson	Signed
1575	2023-04-16 09:00	Anonymous (not verified)	94.188.205.176	Velocity Improvement, LLC	Proprietorship	PO Box 903, Wilton IA 52778	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-16	Kent Grunhovd	velocityimprovement@gmail.com	Wilton	Scott	Iowa	Robin Throne	LaVonne Grunhovd	Signed	(1) The employer does not elect the employers’ liability coverage.	Kent Grunhovd	kgrunhovd3535@gmail.com	Self	Bloomington	McLean	IL	Robin Throne	LaVonne Grunhovd	Signed
1576	2023-04-17 08:32	Anonymous (not verified)	94.188.205.167	Reece Wilson	Limited Liability Company	1431 Starbeck Circle	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-14	Reece J Wilson	rjwilson030@gmail.com	Cedar Falls	Blackhawk	Iowa	Kendall Cotant	Darryl Mason	Signed	(1) The employer does not elect the employers’ liability coverage.	John Richter	jrichter@beecherlaw.com	Business	Waterloo	Blackhawk	Iowa	Kendall Cotant	Jared Hottle	Signed
1578	2023-04-17 15:33	Anonymous (not verified)	94.188.205.174	Spark Train Express LLC	Limited Liability Company	16877 500th St, Pocahontas, IA 50574	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-17	Austin Sparks	sparksaustin.11@gmail.com	Pocahontas	Pocahontas	Iowa	Stephanie Webbink	Christian Lynch	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Sparks	sparksaustin.11@gmail.com	Owner	Pocahontas	Pocahontas	Iowa	Stephanie Webbink	Christian Lynch	Signed
1579	2023-04-17 17:00	Anonymous (not verified)	94.188.205.177	Home provisions siding LLC	Limited Liability Company	1816 Francis avenue apt 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.	2023-04-17	Luis Alberto Ramirez Mendez	luisramirez4308@icloud.com	Desmoines	Polk	Iowa	Alexandra Gomez-Benitez	Marcedez ramirez	Signed	(1) The employer does not elect the employers’ liability coverage.	Luis Alberto Ramirez Mendez	luisramirez4308@icloud.com	None	Des Moines	Polk	Iowa	Alexandra Gomez-Benitez	Marcedez Roxana Ramirez	Signed
1587	2023-04-19 09:12	Anonymous (not verified)	94.188.205.169	Sami Jo T Tappe	Proprietorship	7044 Carey Ct Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-19	Sami Jo Tappe	samijotappe@gmail.com	Johnston	Polk	Iowa	Olga Sanchez	Matthew Tappe	Signed	(1) The employer does not elect the employers’ liability coverage.	Sami Jo Tappe	samijotappe@gmail.com	Self	Johnston	Polk	Iowa	Olga Sanchez	Matthew Tappe	Signed
1588	2023-04-19 11:04	Anonymous (not verified)	94.188.205.174	Peters Tree Service	Proprietorship	205 Melrose St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-19	Timothy F Peters	tim_peters1@hotmail.com	Wall Lake	Sac	Iowa	Bruce Paysen	Roberta Paysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy F Peters	tim_peters1@hotmail.com	Self	Wall Lake	Sac	Iowa	Brace Paysen	Roberta Paysen	Signed
1591	2023-04-21 13:59	Anonymous (not verified)	94.188.207.226	Self employed	Proprietorship	406 s main prairie city	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-21	Thomas Leo carroll	Tom.carroll66@gmail.com	Prairie city	Jasper	Iowa	Tina hellyer	Matt wenthie	Signed	(1) The employer does not elect the employers’ liability coverage.	Tom carroll	Tom.carroll66@gmail.com	Self	Prairie city	Jasper	Iowa	Tina hellyer	Matt whinthy	Signed

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